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Client Intake Form - Kristen H Clark Spiritual Healer, Teacher, Mentor
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Email
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Your email
First and Last Name
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Your answer
Phone Number
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Your answer
Address
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Your answer
Preferred Method of Contact
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Email
Phone Call
Text
Emergency Contact (Name/Phone/Relationship to you)
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Partner or Spouse Name
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Relationship Status
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dating
engaged
married
separated
domestic partnership
Other
How long have you been together?
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Your answer
Children's Names and Ages (with current partner)
Your answer
Children's Names and Ages (with previous partner)
Your answer
Children's Names and Ages (partner came into relationship with)
Your answer
Job Title, Profession, and/or Place of Employment
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Why are you seeking services?
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How did you find out about our services?
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Your answer
Have you had any past experience with coaching or counseling, individually or together? If so, please describe.
Your answer
What is your current title and occupation?
Your answer
What relationship poisons do you currently express in your relationship? (check all that apply)
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blame
criticism
affairs
secrets
addictions
resentment
name-calling
defensiveness
shaming
physical violence
verbal aggression
silent treatment
Required
What relationship poisons does your partner currently express in your relationship? (check all that apply)
*
blame
criticism
affairs
secrets
addictions
resentment
name-calling
defensiveness
shaming
physical violence
verbal aggression
silent treatment
Required
What are your favorite parts of your relationship?
Your answer
What do you want more of in your relationship?
Your answer
What gets in the way of having this?
Your answer
What do you want less of in your relationship?
Your answer
What was the relationship of your parents like?
Your answer
Briefly describe any major past relationships and why they ended.
Your answer
On a scale of 1-5 how fulfilled do you feel in this life area: WORK
Choose
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On a scale of 1-5 how fulfilled do you feel in this life area: SECURITY
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On a scale of 1-5 how fulfilled do you feel in this life area: PURPOSE
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On a scale of 1-5 how fulfilled do you feel in this life area: GROWTH
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On a scale of 1-5 how fulfilled do you feel in this life area: FEELING LIKE A PRIORITY TO YOUR PARTNER
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On a scale of 1-5 how fulfilled do you feel in this life area: BEING ACCEPTED AND ENCOURAGED BY YOUR PARTNER
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On a scale of 1-5 how fulfilled do you feel in this life area: SEXUALITY
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On a scale of 1-5 how fulfilled do you feel in this life area: ADVENTURE
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On a scale of 1-5 how fulfilled do you feel in this life area: SOCIAL CONNECTIONS OUTSIDE YOUR RELATIONSHIP
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On a scale of 1-5 how fulfilled do you feel in this life area: HEALTH
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Do you or your family members have any history with mental illness? If so, please describe.
Your answer
Are you currently on any medications? If so, please list them and for what they are prescribed.
Your answer
Thanks so much for sharing! If there is anything else you want us to know so that we can best serve and support you, you are warmly welcome to share here (optional).
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