New Client Intake Form – Elizabeth Oing Coaching

New Client Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*

Country CodeArea CodePhone Number
If your number is outside the US, which app could you use for contact?

TelegramWhatsApp
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact Info*
Name, Relationship, and Phone

Medical/Health History
Have you been under a doctor’s care for a specific health condition within the last 24 months? If yes, what?*
If yes above, physician's name & contact information
Email or phone
Please list any significant medical conditions, diagnoses, and health history
Are you currently under the care of a counselor and/or therapist, psychologist, psychiatrist? If yes, for what?*
If yes above, therapist's name & contact information
Email or phone
Please include all medications and supplements you are currently taking

Reason for Visit*
What does this problem stop you from doing?*
What have you tried to resolve this problem that hasn't worked?*
What have you tried to resolve this problem that has worked (even partially)?*
Why have you decided to make this change? Why now?*
Desired Outcome*
Have you experienced any form of coaching or hypnotherapy before? If so, please describe type/experience*
How did you find me, or who may I thank for the referral?*
I affirm that the information I have listed above is complete and correct to the best of my knowledge.

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New Client Form