Coaching Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Today's Date * MM DD YYYY Emergency Contact Information For this section, we'll need the name and contact info for your Emergency Contact. Name * First Name Last Name Phone * (###) ### #### Mental/ Physical Health Do you have any medical conditions I should be aware of? In the event of a medical condition, do you have the support you need? Do you have any mental health concerns I should be aware of? In the event of a mental health condition, do you have the support you need? Have you had or are you currently receiving mental health therapy? Family - Current & Original What is your current primary relationship status (if you have one)? Briefly describe your relationship with your partner (if you have one) Who is currently living with you? Briefly describe your relationship with your children (if you have any) Who makes up your family of origin? (Are they living? Deceased?) Briefly describe your relationship with your parents. Briefly describe your relationship with your siblings (if any) Is there anything significant I should know about your current family or family of origin? I.e. alcoholism, early death, illness etc. Religious / Spiritual History Do you consider yourself religious? Spiritual? Atheist? Agnostic? Enneagram Information What is your Type in Personality, Dominant Subtype and Subtype Sequence (if you know it)? Why do you want to do this Enneagram work now? What are you hoping to gain from our time together? What are some specific areas of focus you would like us to focus on? Personality patterns Primary relationships Work/Career Parenting Family of Origin relationships Spirituality Is there anything else you would like me to know at this time? Thank you for contacting me! You’ll hear back from me shortly. If you haven’t heard from me in a few days, check your spam folder.
