Want Dr. Robin as your couples coach? - Robin Buckley Coaching

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Client Name

First Middle Last

Date of Birth

Street Address

Street Address Address Line 2 City State ZIP Code

Preferred Email Address*

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Yes, keep me up to date with latest news and updates.

Client's Preferred Phone

Phone Type

Cell

Home

Work

Gender

Occupation

Employer or School (if student)

Marital status

Spouse/Partner (if applicable) and Occupation

Other family members and ages

(please note whether living in or outside of the home)

How did you learn about this practice

FINANCIALLY RESPONSIBLE PARTY

An adult client or an adult guardian who has assumed the cost of treatment. Payment is expected at the time of service.

Name

First Last

Relationship

Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact

Relationship

Phone

Presenting challenges to address in coaching: How do these impact the relationship? How do these impact you? Describe emotionally, cognitively, physically, sexually.

HISTORY OF DIFFICULTY AND PRECIPITATING FACTORS

Goals you want to accomplish through coaching

If none reported, check here

None reported

PERTINENT BACKGROUND

(# of siblings, marriages/significant relationships, children, impacting events, e.g. moves, developmental changes, sexual/physical/emotional abuse, trauma, divorce.)

SOCIAL/SPIRITUAL/INTERPERSONAL SUPPORT SYSTEM OR ACTIVITIES

If none reported, check here

None reported

Abuse &/or Neglect

Yes

If Yes to any of the above, please list contact person

What are your strengths, or other things you are particularly good at or enjoy doing?

Medical Information

Present health of client

Previous medication (not for common illnesses)

Current medications (include all and who is prescribing them)

Have you been hospitalized or had surgeries (please describe)

Any family history of mental health concerns?

(i.e. Adhd, learning disabilities, depression alcoholism, anxiety) or neurological disorders (i.e. seizures, Tourettes, autism)

Other care professionals you are currently undergoing treatment with including a therapist doing individual counseling or others (e.g. acupuncturist, chiropractor, medical specialists, etc.)

Physician

Phone

Address

Street Address Address Line 2 City State ZIP Code

Other

Phone

Address

Street Address Address Line 2 City State ZIP Code

Other

Phone

Address

Street Address Address Line 2 City State ZIP Code

Other

Phone

Address

Street Address Address Line 2 City State ZIP Code

Any other information that you feel is important for me to know?

Name

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