New client intake form

Basic information about you

Name *

First

Last

Preferred pronouns

(For example: he/him/his, she/her/hers, they/their/theirs)

Email *

Cell phone number *

Alternate phone number, if any

For example, home or work number

Okay to leave messages?

Cell
Alternate phone

Please check all that apply

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency contact information

Emergency contact's name *

First

Last

Contact number *

Relationship to you *

Background information about you

Please share as much or as little as you want--whatever you'd like me to know about you that you didn't get a chance to share during our initial clearness call. If a question doesn't resonate with you, please feel free to skip it.

Anything you’d like me to know about your background & identities (e.g., your age, racial/cultural background, sexual orientation and/or gender identity, places you’ve lived, education, etc.)?

Anything you'd like me to know about your spirituality?

How do you spend your time most days (for example, family, work, volunteering, passion projects, and/or things you do for fun)?

Anything else you’d like me to know about you?

Any questions or comments?