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Client intake form
Please fill out the form with as much information as you are comfortable sharing.
We value your privacy. All information you provide will be handled in accordance with the Privacy Act 1988 and kept strictly confidential.
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Name
*
Your answer
Year of birth
Your answer
Suburb
Your answer
Phone number
*
Your answer
Martial status.
Number of children and ages.
Your answer
Ocupation
Your answer
Please name up to three issues you would like to work on.
For each issue, rate its current impact on your life on a scale of 1 to 10, with
10
being the most severe or challenging state.
Your answer
Rate Issue #1
1= there is no issue. 10 = worst state possible
1
2
3
4
5
6
7
8
9
10
Clear selection
Rate Issue #2
1= there is no issue. 10 = worst state possible
1
2
3
4
5
6
7
8
9
10
Clear selection
Rate Issue #3
1= there is no issue. 10 = worst state possible
1
2
3
4
5
6
7
8
9
10
Clear selection
How are you currently managing these issues?
Please describe any strategies, methods, or support systems you are using at this time.
Your answer
Are you committed to improving these aspects of your life?
Please note that this program, like any form of therapy or coaching, is most effective when clients are genuinely open to and ready for change.
Yes
No
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