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Mental Health Coaching Telehealth Services Client Intake Form

Welcome! Thank you for choosing [Your Coaching Service Name]. This form helps us understand your needs and determine if our coaching services are a good fit for you. Please answer all questions honestly and thoroughly. All information provided will be kept confidential.

I. Personal Information

First Name

Last Name

Date of Birth

Gender

Preferred Pronouns

Phone Number

Email Address

Mailing Address

City

State/Province

Postal/Zip Code

Emergency Contact Name

Emergency Contact Number

Emergency Contact Relationship

II. Coaching Goals & Objectives

What specific areas of your mental well-being would you like to improve?

Stress management

Anxiety reduction

Emotional regulation

Self-esteem

Goal setting

Other (Please specify):

What are your primary goals for mental health coaching? (Please be specific and measurable)

What does success look like to you in this coaching relationship?

What challenges have you faced in achieving these goals in the past?

What strengths and resources do you currently possess that you believe will support your coaching journey?

III. Current Mental and Emotional State

On a scale of 1-10 (1 being "not at all" and 10 being "extremely"), how would you rate your current overall mental well-being?

Have you been experiencing any of the following in the past month? (Check all that apply)

Persistent sadness or low mood

Excessive worry or anxiety

Difficulty sleeping or changes in sleep patterns

Changes in appetite or weight

Difficulty concentrating or making decisions

Feelings of hopelessness or helplessness

Loss of interest in activities you once enjoyed

Irritability or increased anger

Thoughts of self-harm or suicide

Other (Please specify):

If you select "Thoughts of self-harm or suicide", please provide details:

Are you currently under the care of a mental health professional (e.g., therapist, psychiatrist)?

If yes, please provide their name and contact information:

Are you currently taking any medications for mental health conditions?

If yes, please list them:

Have you ever been diagnosed with a mental health condition?

If yes, please specify:

Do you have any history of trauma or significant life events that impact your mental health?

IV. Coaching Services Options

(Please select the service(s) that interest you)


Individual Coaching Sessions:

  • Focus: Personalized one-on-one sessions to address specific mental health goals.
  • Frequency: (Options: Weekly, bi-weekly, monthly)
  • Session Duration: (Options: 30 minutes, 45 minutes, 60 minutes)

Stress Management Coaching:

  • Focus: Techniques for managing stress, improving resilience, and promoting relaxation.
  • Specific techniques: breathing exercises, mindfulness, time management.

Anxiety Reduction Coaching:

  • Focus: Strategies for reducing anxiety symptoms, managing triggers, and building coping skills.
  • Specific techniques: Cognitive restructuring, grounding techniques, exposure techniques (when appropriate and in coaching boundaries).

Emotional Regulation Coaching:

  • Focus: Developing skills to identify, understand, and manage emotions effectively.
  • Specific techniques: emotional awareness, distress tolerance, interpersonal effectiveness.

Goal Setting & Motivation Coaching:

  • Focus: Clarifying goals, developing action plans, and maintaining motivation.

Self-Esteem & Confidence Coaching:

  • Focus: Building self-acceptance, challenging negative self-talk, and enhancing self-confidence.

Group Coaching (If Applicable):

  • Focus: Support and learning within a group setting, addressing shared mental health challenges. (Specify topics and availability)

Specific skill coaching:

  • Focus: Building social skills, communication skills, or other specific skills.

V. Suitability for Coaching

Are you aware that mental health coaching is not a substitute for therapy or psychiatric treatment?

Do you understand that coaches do not diagnose or treat mental health disorders?

Are you willing to actively participate in the coaching process, including completing assignments and practicing new skills?

Are you comfortable with receiving coaching via telehealth (video or phone)?

Do you have access to a private and quiet space for coaching sessions?

Do you have reliable internet access and a device suitable for video conferencing?

Are you committed to maintaining confidentiality during coaching sessions?

If you are experiencing severe mental health symptoms, do you understand that you may be referred to a mental health professional?

Do you understand that coaching is a partnership, and your active participation is required for successful outcomes?

Are you willing to communicate honestly and openly with your coach?

VI. Technology and Logistics

What type of device will you be using for telehealth sessions?

Computer

Smartphone

Tablet

What is your preferred platform for video conferencing?

What are your preferred days for coaching sessions?

What are your preferred times for coaching sessions?

VI. Consent and Agreement

By signing below, you acknowledge that you have read and understood the information provided in this form and agree to participate in mental health coaching services.

 

Client Signature:

Client Intake Form Insights

Please remove this client intake form insights section before publishing.


Important Notes:

  • This form should be reviewed and updated periodically.
  • Always prioritize client safety and well-being.
  • Ensure compliance with all applicable privacy laws and regulations.
  • If a client indicates suicidal ideation, or any intent to harm themselves, or others, you must follow your ethical and legal obligation to report this, and to encourage the client to seek immediate help from trained mental health professionals.
  • It is vital to have clear boundaries between coaching and therapy, and to make sure the client understands those boundaries.

This detailed intake form will help you gather essential information and determine if your coaching services are a good fit for each client.


Let's break down the detailed insights into this Mental Health Coaching Telehealth Services Client Intake Form, section by section:


I. Personal Information:

  • Purpose: This section establishes basic client identification and contact information. It also includes an emergency contact, which is crucial for safety, especially in telehealth settings.

  • Insights:

    "Preferred Pronouns" acknowledges and respects gender identity, fostering inclusivity.
    "How did you hear about our services?" provides valuable marketing data.
    The emergency contact information is vital for safety and ethical practice.

II. Coaching Goals & Objectives:

  • Purpose: This section delves into the client's motivation for seeking coaching and helps define the desired outcomes.

  • Insights:

    Specific and measurable goals are essential for tracking progress and ensuring accountability.
    Understanding past challenges helps identify potential obstacles and tailor the coaching approach.
    Identifying existing strengths and resources empowers the client and builds a foundation for success.

III. Current Mental and Emotional State:

  • Purpose: This section assesses the client's current mental health status and helps determine if coaching is appropriate.

  • Insights:

    The numerical rating scale provides a baseline for tracking changes over time.
    The checklist of common mental health symptoms helps identify potential areas of concern.
    Questions about current and past mental health treatment are crucial for assessing suitability for coaching and potential need for referral.
    It is vital to be aware of the difference between coaching, and therapy. If the client is presenting with serious mental health conditions, then they need to be referred to a therapist, or psychiatrist.
    Any indication of suicidal ideation or self-harm must be taken seriously and addressed immediately.

IV. Coaching Services Options:

  • Purpose: This section outlines the available coaching services and allows the client to choose the options that best meet their needs.

  • Insights:

    Offering a variety of services caters to diverse client needs and preferences.
    Clearly defining the focus and techniques of each service helps clients make informed decisions.
    Group coaching options, if available, can provide valuable peer support and community.
    Offering specific skill based coaching, allows you to target very specific client needs.

V. Suitability for Coaching:

  • Purpose: This section assesses the client's understanding of coaching and their commitment to the process.

  • Insights:

    Explicitly stating the limitations of coaching (i.e., not a substitute for therapy) is essential for ethical practice.
    Assessing the client's willingness to participate actively is crucial for successful outcomes.
    Ensuring the client has the necessary technology and a private space for telehealth sessions is vital.
    This section protects you, and the client, by making sure that the client understands the boundries of coaching.
    The questions in this section also provide a good opportunity to explain the coaching process to the client.

VI. Technology and Logistics:

  • Purpose: This section gathers information about the client's technology and scheduling preferences.

  • Insights:

    Identifying potential technology issues in advance helps prevent disruptions during sessions.
    Flexible scheduling options enhance accessibility and convenience.

VII. Consent and Agreement:

  • Purpose: This section ensures that the client has read and understood the information provided and agrees to participate in coaching.

  • Insights:

    A signed consent form is essential for legal and ethical compliance.

VIII. For Coach Use Only:

  • Purpose: This section provides space for the coach to document their initial assessment, suitability determination, and recommended coaching plan.

  • Insights:

    This section promotes consistency and accountability in the coaching process.
    It is very important to document everything.

Overall Insights:

  • Client-centered approach: The form prioritizes the client's needs, preferences, and well-being.
  • Ethical considerations: The form addresses crucial ethical considerations, such as confidentiality, informed consent, and referral procedures.
  • Comprehensive assessment: The form gathers a wide range of information to ensure a thorough assessment of the client's needs and suitability for coaching.
  • Telehealth specific: The form addresses the unique challenges and considerations of providing coaching via telehealth.
  • Clarity and transparency: The form uses clear and concise language to ensure that clients understand the coaching process and their responsibilities.
  • Safety First: The form prioritizes client safety by including emergency contact information and assessing potential risks.

By carefully analyzing the responses to this intake form, coaches can gain valuable insights into their clients' needs, tailor their services accordingly, and build strong and effective coaching relationships.


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