Welcome to the New Patient Form!

Please fill out This form to the best of your ability

If there are areas on the personal section of the form that you may not want to fill out, or that you prefer to speak about in person, that’s ok.

Just do your best!

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Can you give a short version of what brought you to decide to begin this journey with me?

Do you feel like you know yourself well, do you feel more lost, or somewhere in between?

Sometimes we can know ourselves, but have made choices that lead us away from true self and need to get alignment. Other times some of us may not really feel like we know ourselves at all. This question helps us know which may be more likely and create our sessions more directly to what's needed.

Please describe any current physical, mental or emotional symptoms you are currently experiencing:

Can you share your personal relationship with change, and how you feel you typically navigate transitions?

Can you describe what coping strategies do you currently use to manage pain or fear, and how effective do you feel they are?

Please list and then give a number from 0-10 on how effective with 0 being habitually ineffective and 10 being the best.

What is the biggest fallback technique you rely on, and what do you believe it brings to your life—positively or negatively?

For example - FREEZE: makes me feel safe in the moment but keeps me stuck / REACHING OUT TO FRIENDS: makes me think and reflect and feel calm enough to make decisions etc. ..

What new approaches or strategies, if any, have you considered or desired but felt hesitant to try, and why?

How open are you to exploring techniques that may challenge your current ways of thinking or feeling?

If a new strategy felt uncomfortable at first, what would help you stick with it long enough to see its potential benefits?

Is there something specific that you would love to see by the end of our sessions together?

Are you aware how your female menstrual cycle could possibly be affecting your thoughts and actions?

(This is true even if you no longer have a physical cycle.)

Is there anything else you would like to share here that I may not have asked about?

Agreement between parties: Please type your name below after reading.

*I understand that Life Coaching is a collaborative partnership designed to support personal and professional growth. I am dedicated to providing guidance, support, and resources, however, the success of this process also depends on the client’s commitment, effort, and willingness to take action, therefore outcomes are influenced by many factors and cannot be guaranteed. Confidentiality All coaching sessions are private and confidential. Information shared will not be disclosed to third parties unless required by law or with your written consent. Payment and Scheduling Full payment is required to confirm your session(s). All sessions must be scheduled within three months of purchase unless otherwise agreed upon. A minimum of 24 hours' notice is required to reschedule a session. Missed appointments or cancellations with less than 24 hours’ notice will not be refunded or rescheduled. Due to the nature of life coaching services, all payments are final, and no refunds will be issued. Clients are responsible for seeking further appropriate support if needed. By proceeding with life coaching services, you acknowledge and agree to these terms and conditions.