New Client Intake Form

413 376 5070
amy@coachingbyamy.com

Client Information

First name

Last name

Mailing Address

City, State

Cell Phone

Email address

Date of Birth

Name of Partner/Spouse

Briefly describe why you are interested in Relationship Coaching

How did you find out about Relationship Coaching with Amy Newshore?

Emergency Contact

Add another emergency contact

More Information About You

Have you previously received individual therapy or couples therapy?

No Yes

If yes, please specify which one or write "both".

Are you currently in individual therapy?

Yes No

Who is your health insurance provider?

This is very helpful information for me to help individuals find therapists if needed which can greatly benefit the work we do together in couples sessions.

Is there anything regarding your mental health that I should be aware of?

Do you have any children?

Yes No

What is your highest level of education?

Are you currently employed?

Yes No

If yes, what is your current occupation?

Do you use drugs?

Regularly Occasionally No

Do you smoke?

Regularly Occasionally No

Do you drink alcohol?

Regularly Occasionally No

Do you drink caffeine?

Regularly Occasionally No

Do you gamble?

Regularly Occasionally No

How often do you get a full night of sleep?

Regularly Occasionally Never

Do you exercise?

Regularly Occasionally No

Do you have a healthy and balanced diet?

Regularly Occasionally No

How often do you have time for fun and recreational activities?

Regularly Occasionally Never

Describe any goals or outcomes you hope to achieve from working with me?

Describe any significant life changes or stressful events that you may have recently experienced.

Is there anything else that would be important for me to know?

What is your current feeling about starting Relationship Coaching with me? Excited? Wary? Hopeful? Scared? Etc.

Date

I confirm that I have read and understood the welcome email in its entirety and accept the terms of the Cancellation and Payment Policy.

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