Telehealth Client Intake Form for Mental Health Coaching

I. Client Information

First Name

Last Name


Preferred Name (if different)

Date of Birth

Gender


Phone Number

Email Address

Preferred Method of Contact

Mailing Address

City

State/Province

Postal/Zip Code


Emergency Contact Name

Emergency Contact Number


Emergency Contact Relationship

II. Coaching Services Offered

Please review the following coaching services and indicate which ones you are interested in:

III. Client Suitability Assessment

What are your primary reasons for seeking mental health coaching?

Have you previously worked with a mental health coach, therapist, or counselor?

What are your goals for coaching?

Do you currently experience any of the following? (Check all that apply)

How would you rate your current mental health? On a scale of 1-10 (1 being "Poor" and 10 being "Excellent")

Are you currently taking any medications for mental health concerns?

Have you been diagnosed with any mental health conditions?

Do you have any physical health conditions that may impact your mental health?

What is your preferred coaching format?

How often would you like to schedule coaching sessions?

What is your availability for coaching sessions?

Days:

Times:

Do you have any preferences for your coach (e.g., gender, background, coaching style)?

What do you hope to achieve through mental health coaching?

Are there any specific challenges or barriers you anticipate in participating in coaching?

Do you have any concerns about telehealth services (e.g., technology, privacy)?

IV. Consent and Agreement

I understand that mental health coaching is not a substitute for therapy or medical treatment.

I agree to participate in telehealth sessions and understand the importance of a private, secure environment during sessions.

I consent to the use of electronic communication for coaching sessions and understand the potential risks and benefits.

I have read and agreed to the terms and conditions of the coaching services.

Client Signature:


Client Intake Form Insights

Please remove this client intake form insights section before publishing.


Below is a detailed breakdown of Client Intake Form, including insights into its purpose, structure, and the significance of each section. This form is designed to ensure a comprehensive understanding of the client’s needs, preferences, and suitability for telehealth coaching services.


Purpose of the Client Intake Form

  1. Gather Essential Information: Collects basic demographic and contact details to establish communication and identify the client.
  2. Assess Client Needs: Helps understand the client’s mental health concerns, goals, and expectations.
  3. Determine Suitability: Evaluates whether the client is a good fit for mental health coaching and telehealth services.
  4. Personalize Services: Tailors coaching sessions to the client’s specific needs and preferences.
  5. Establish Consent and Boundaries: Ensures the client understands the nature of coaching, telehealth, and their responsibilities.

Detailed Insights into Each Section

1. Client Information

  • Purpose: To identify the client and establish a professional relationship.

  • Key Insights:

    Preferred Name: Respects the client’s identity and fosters a welcoming environment.
    Emergency Contact: Ensures safety and provides a point of contact in case of emergencies.
    Preferred Method of Contact: Facilitates effective communication based on the client’s comfort.

2. Coaching Services Offered

  • Purpose: To inform the client about available services and identify their areas of interest.
  • Key Insights:

    Comprehensive List: Covers a wide range of coaching areas (e.g., stress management, anxiety, self-esteem) to address diverse needs.
    Customization: Allows clients to select specific services, ensuring the coaching is aligned with their goals.
    Other Option: Provides flexibility for clients to express unique needs not listed.

3. Client Suitability Assessment

  • Purpose: To evaluate the client’s mental health status, goals, and readiness for coaching.

  • Key Insights:
    Primary Reasons for Seeking Coaching: Helps the coach understand the client’s motivations and expectations.
    Previous Experience: Provides context about the client’s history with mental health support.
    Current Mental Health Status: Identifies symptoms (e.g., anxiety, depression) that may require specialized attention or referral to a therapist.
    Medications and Diagnoses: Ensures the coach is aware of any medical or psychological conditions that may impact coaching.
    Physical Health Conditions: Highlights potential connections between physical and mental health.
    Coaching Preferences: Tailors the format, frequency, and timing of sessions to the client’s lifestyle.
    Challenges and Barriers: Anticipates obstacles (e.g., time constraints, technology issues) to ensure smooth participation.
    Telehealth Concerns: Addresses any hesitations about virtual sessions, ensuring the client feels comfortable and secure.

4. Consent and Agreement

  • Purpose: To establish clear boundaries, responsibilities, and consent for telehealth coaching.

  • Key Insights:
    Coaching vs. Therapy: Clarifies that coaching is not a substitute for therapy or medical treatment, setting realistic expectations.
    Telehealth Consent: Ensures the client understands the nature of virtual sessions and agrees to participate.
    Privacy and Security: Reassures the client that their information and sessions will remain confidential.
    Terms and Conditions: Formalizes the client’s agreement to the coaching process and policies.

Why This Form is Effective

  1. Client-Centered Approach: Focuses on the client’s needs, preferences, and goals, ensuring a personalized coaching experience.
  2. Comprehensive Assessment: Covers all aspects of the client’s mental health, history, and expectations, reducing the risk of misunderstandings.
  3. Clear Communication: Sets expectations about the coaching process, telehealth services, and the client’s role.
  4. Safety and Ethics: Includes emergency contact information and consent forms to prioritize the client’s well-being and privacy.
  5. Flexibility: Allows clients to express unique needs and preferences, making the form adaptable to diverse populations.

How to Use This Form

  1. Pre-Session Completion: Ask the client to fill out the form before the first session to save time and provide the coach with necessary information.
  2. Review and Clarify: During the initial session, review the form with the client to clarify any responses and address concerns.
  3. Tailor the Approach: Use the information to design a coaching plan that aligns with the client’s goals and preferences.
  4. Monitor Progress: Refer back to the form periodically to assess progress and adjust the coaching approach as needed.

This Client Intake Form is a vital tool for mental health coaches to provide effective, personalized, and ethical telehealth services. It ensures that both the coach and client are aligned in their goals and expectations, fostering a productive and supportive coaching relationship.


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