Intake Form for Potential Coaching Clients

Thank you for taking the time to fill out this intake form. Your responses help me understand your needs and goals so that we can create a supportive, personalized plan for you. All information will be kept confidential.

First name

Last name

Address

Phone

Emergency Contacts

Who do you care for (relationship, age, general needs)?

Current living situation of the person being cared for?

Approximate hours per week you provide care?

Other caregivers involved (family, professional, etc.)

Any recent or upcoming changes in care (moves, medical procedures, etc.)?

Any relevant medical or mental health diagnoses for yourself or the care recipient?

Medications / treatments you manage:

Current stress levels (low / moderate / high)

Challenges or concerns you experience as a caregiver (emotional, physical, logistical)

Trauma history or triggers you feel are important for me to know (optional but helpful)

What are the top 3 challenges you face right now?

What support would be most helpful (check all that apply):

What outcomes would make this support successful for you?

Preferred mode of communication (email, phone, text, in-person)

Availability / best times for sessions or visits:

Any special considerations (sensory, mobility, cognitive, emotional)

What are your immediate caregiving challenges?

What emotional support do you currently have?

Are there any safety concerns for the care recipient or yourself?

Are there any triggers or past trauma that might influence our work together?

What are your short-term and long-term goals for care?

Disclaimer / Important Note: I am not a medical doctor, psychologist, or licensed mental health professional. My coaching and support are based on my personal experiences navigating caregiving, trauma, and family dynamics in my own life.

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