Coaching Intake Form

This form helps me understand the nuances of your situation so I can support you with clarity, compassion, and the right level of guidance. Every move, every medical shift, every family dynamic has its own rhythm, and thoughtful planning makes all the difference. Share what you can, and I’ll take it from there—creating a plan that lightens your load and steadies the path ahead.

First name

Last name

Phone

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?

What caregiving situation would you like help thinking through right now? (One or two sentences is enough.)

What feels most unclear, heavy, or difficult about this situation? (e.g., a decision, a relationship dynamic, ongoing doubt, something that feels “off”)

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

What have you already tried, considered, or been told about this situation? (Brief notes are fine.)

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?

Are there other people involved whose opinions or actions are influencing this situation? (e.g., siblings, partner, medical professionals, facility staff)

What outcomes would make this support successful for you?

On a scale of 1–10, how mentally or emotionally taxed do you feel by this situation right now? (Optional: “You can answer intuitively.”)

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?

Is there anything important you’d like me to know before we meet? (Optional)

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

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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