Welcome!

New Client Questionnaire

I am so excited to begin this journey with you! Please take some time to fill out the following information and return to me prior to our first session together.

BASIC INFORMATION

Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

What is your preferred mode of contact and communication?

Text

Phone Call

Please provide the name and contact information for the person to contact in case of an emergency.

Name

Relationship

Phone Number

(###)

###

####

HEALTH & BACKGROUND

Do you currently have any medical conditions or health issues that are impacting your wellbeing? Or that could impact your participation in light activities in the natural environment?

Rate your current stress level on a scale of 1-10.

Please list any mental health challenges that you’ve been diagnosed with or struggle with on a consistent basis (depression, anxiety, adhd, ocd, etc.).

Have you previously worked with a therapist, counselor, or other mental health professional? If so, please describe any info from that experience that might be helpful to our work together.

Please briefly share any of your personal story that feels relevant to our work together (family/work life, any significant losses or events you have experienced, etc.)

RESOURCES

What is the most positive thing in your life right now?

Please list resources you already have in your life (therapists, mentors, friends, practices you’re involved in, hobbies, relaxation techniques, etc).

If you are currently seeing any other practitioners for healing or mental health, are you interested in me partnering with them to support your growth?

COACHING

Please briefly name or describe the issues which you are seeking coaching for.

If you could envision yourself transformed by our time together, what would that look like?

Without going into detail, please name or list your greatest challenges right now.

What is the most important goal in your life right now?

How committed are you? How important is this to you?

OTHER JUICY INFO

I study Evolutionary Astrology and archetypal psychology. If you have taken any other personality or archetypal assessments that you’d like to incorporate into our work together (Astrological Signs, Enneagram, Love Languages, etc.) please list below.

Anything else you would like me to know or any specific needs you might have?

Thank you for sharing this information with me! All the information provided will be held in full confidentiality. If you have any questions before we get started, please feel free to contact me at any time.