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.
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
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?
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):
Are you currently under the care of a mental health professional (e.g., therapist, psychiatrist)?
Are you currently taking any medications for mental health conditions?
Have you ever been diagnosed with a mental health condition?
Do you have any history of trauma or significant life events that impact your mental health?
(Please select the service(s) that interest you)
Individual Coaching Sessions:
Stress Management Coaching:
Anxiety Reduction Coaching:
Emotional Regulation Coaching:
Goal Setting & Motivation Coaching:
Self-Esteem & Confidence Coaching:
Group Coaching (If Applicable):
Specific skill 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?
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?
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 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:
II. Coaching Goals & Objectives:
III. Current Mental and Emotional State:
IV. Coaching Services Options:
V. Suitability for Coaching:
VI. Technology and Logistics:
VII. Consent and Agreement:
VIII. For Coach Use Only:
Overall Insights:
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.