confidential client profile 

This information will be shared between you and your coach only. Please answer of the questions as completely as you are willing. Do not hesitate to ask any questions with arise for you. 

Name *
Name
Date *
Date
Were you adopted?
If Yes, do you know your birth mother or father
Do you have children?
Have you ever been hospitalized for emotional reasons?
Have you ever been in an accident or other traumatic experience? (e.g. Natural Disaster, War, Violent Crime, etc)
Have you or any of your family members ever been sexually molested or physically abused?
Have you or your family members ever been arrested for and/or convicted of a felony?
Have you or any members of your immediate family ever declared bankruptcy?
Have you or any member of your family ever served in the military?
Has any family member or close friend died within the last year?
How close were you
Are you and/or any of your immediate family members currently in therapy and/or under the care of a doctor or other medical professional?
Have you or any member of your immediate family had difficulties with alcohol, drugs, or eating disorders
Is there anything is your life that does not serve you that you might have difficulty giving up or letting go of?
1) Spirituality 2) Mentally 3) Emotionally 4)Physically 5) Nutritionally

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