Individual Coaching Form

Individual Coaching Intake Form

First name

Last name

Phone

What time zone do you live in?

Which best describes you?

Man seeking recovery support after betrayal

Female betrayed partner seeking support

Other

Have you ever been diagnosed with a mental health issue/disorder? If yes, please indicate the diagnosis

If yes, please describe what kind of treatment, medication, or support you're currently receiving.

Note: I am unable to offer coaching if there is a mental health issue that is not currently being treated.

How long have you been in recovery?

In the past 30 days, have there been any new discoveries, disclosures, or significant revelations?

Yes

Unsure

Have you been through a formal disclosure process with a therapist, coach, mentor, etc?

Has there been any physical violence in your relationship with your partner in the past two years? (includes any pushing, hitting, kicking, restraining, or other physical aggression from either person). If yes, please explain briefly:

Note: I am unable to offer coaching if there has been any physical violence in the relationship in the past two years.

How would you know that the help you're receiving is working? Identify 3 outcomes you hope to see from coaching -

What feels most urgent right now?

Anything else you'd like to share that might be helpful?

How did you hear about us?

Coaching is not a substitute for therapy, counseling, or medical treatment. I understand that coaching focuses on personal growth, accountability, and forward progress rather than diagnosis or treatment of mental illness. I acknowledge and agree to these terms.

Individual Coaching Intake Form

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