Pre Coaching Questionnaire

Your Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Important Person #1 *

First Name

Last Name

Name of Important Person #2

First Name

Last Name

Name of Important Person #3

First Name

Last Name

Name of Important Person #4

First Name

Last Name

Emergency Contact's Name *

First Name

Last Name

Emergency Contact's Phone Number *

Country

(###)

###

####

Are you undergoing treatment for your mental health? *

Are you currently under treatment for any psychiatric or mental health conditions, or are you working with a therapist or other mental health professional?

Yes

No

Mental Health History *

Have you ever, at any time in your life, undergone therapeutic treatment for any of the following: bi-polar/manic depression; post-traumatic stress; clinical depression; eating disorders; suicide attempts?

Yes

No

Do you have a reference point that you use to connect with something larger than this human experience (i.e. God, higher power, sense of Universal connection)? (Note: The answer can be no!) *

Yes

No