New Client intake form If you are new to working with Brieana Thompson, please fill in the below client intake form below. Full Name * First Name Last Name Date of Birth * Preferred Pronouns * How did you hear about us? Phone Number Please State Country (###) ### #### May we leave a message? Yes No Email Address * Please State May we leave a message? Yes No Home Address * Please State Emergency Contact * Emergency contact relationship to you * Emergency contact phone number * If employed, what is your occupation? * If employed, how would you rate the quality of your job/role? 1 ( Poor ) 2 3 4 5 6 7 8 9 10 ( Great ) Marital/Relationship Status How many children do you have? Have you had any previous coaching/therapy? Yes No If you answered yes, what was your previous Coach/Therapist's name? Are you currently under the care of another therapist, professional counsellor, or psychiatrist? Yes No If you answered yes, what is the name & number of the practitioner you are seeing? Are you taking prescribed psychiatric medication? If yes, what? Have you ever taken prescribed psychiatric medication? If yes, what? Please describe your primary reason for seeking coaching How would you describe your health currently? Do you have any physical symptoms or health concerns that are impacting your quality of life? i.e. headaches, sleep disturbances, change in eating behaviours, injury. If so, please describe. Have you experienced any significant stressors in the past 12 months? Please describe. How often do you consume alcohol? Daily Weekly Monthly Seldom Never In a typical session, how many alcoholic beverages will you drink? How often do you engage in recreational drug use? Daily Weekly Monthly Seldom Never Have you had suicidal thoughts recently? Yes No If yes, what is the frequency of these thoughts? Daily Weekly Monthly Seldom Never Have you ever experienced: (tick all that apply) Addiction Burnout Extreme Depressed Mood Alcohol/Substance Abuse Eating Disorder Body Dysmorphia Phobias Memory Loss Extreme Mood Swings Panic or Anxiety Attacks Perfectionism Sleep Disturbance Suicidal Thoughts Homicidal Thoughts Thought disorganization and confusion Withdrawal/Isolation How would you rate the quality of your friendships? 1 ( Poor ) 2 3 4 5 6 7 8 9 10 ( Great ) How would you rate the quality of your family relationships? 1 ( Poor ) 2 3 4 5 6 7 8 9 10 ( Great ) If in a romantic relationship, how would you rate the quality of your relationship? 1 ( Poor ) 2 3 4 5 6 7 8 9 10 ( Great ) If employed, how would you rate the quality of your work relationships? 1 ( Poor ) 2 3 4 5 6 7 8 9 10 ( Great ) Do you consider yourself as religious? Yes No If you answered yes, what is your faith? If you answered no, do you consider yourself spiritual? Yes No Has a member of your family experienced any of the following: Addiction Depression Bipolar Disorder Anxiety Disorder Eating Disorder Substance Abuse Neurodiversity Suicide Attempts History of Trauma If you ticked any of the boxes above, please list the relation and what they experienced i.e. mother - anxiety disorder, uncle - substance abuse Is there anything else you want to share? Please tick that you acknowledge the follwoing * I acknowledge that as a coach, Brieana Thompson is obligated to report any instances of illegal activity disclosed during coaching sessions in accordance with applicable laws and regulations I understand that coaching sessions are conducted with strict confidentiality, with exception to legal mandates, supervisory oversight, and in instances where there is a foreseeable risk of harm or safety concerns I acknowledge that Brieana Thompson is not a licensed medical professional and that coaching services provided are not intended to replace or substitute for medical or psychological treatment. Should I require medical or psychological assistance, I understand that it is my responsibility to seek guidance from a qualified healthcare provider Thank you for completing your new client intake form. I looking forward to our coaching session together.** Please note, all details provided are confidential and used for coaching purposes only.
