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Transformational Coaching Intake Form
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Email
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Your email
First and Last Name:
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Your answer
Preferred Pronoun(s):
She/Her
He/Him
They/Them
Other
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Street address:
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Your answer
Phone number:
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Your answer
Date of Birth:
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MM
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DD
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YYYY
Emergency Contact and Phone Number:
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Your answer
How did you hear about Scott?
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Your answer
What is your current occupation or field of interest? if not currently employed, please describe
your daily structure.
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Your answer
What concerns have brought you here?
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Your answer
What are your hopes for our work together?
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Your answer
Please rate your daily stress level:
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No Stress
1
2
3
4
5
6
7
8
9
10
Very Stressed
What do you do to relieve your stress?
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Your answer
Please list any medications and what they are for.
Your answer
Please take this short quiz on trauma and report your ACE score.
https://americanspcc.org/take-the-aces-quiz/
*
Your answer
Do you have a history of substance abuse? If so, have you used this substance in the last six months?
Your answer
Have you been diagnosed and/or hospitalized for any psychiatric issues? If so, when?
Your answer
Have you ever seriously thought about or attempted suicide?
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Yes
No
Have you done healing work before? What kind? For how long? How was your experience with it? Please share in as much detail as you'd like what helped and/or got in the way that might benefit our work together.
Your answer
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