CLIENT INFORMATION
Client’s name:…………………………………………………
Date: __ _/___ / ___
Gender:
Age:…………….
F / M
Date of birth: __ _/___ / ___ _
Address:………………………………………………………………………………..
City: ……………………………….Zip:
……………….. State: ……………………………….
Phone (home): ……………………………….(work): ……………………………….
Email Address:…………………………………………………………………………………………….
Your Family
Name
Age
Partners Name
Children
Step Children or other
children you care for.
Is there any other person
who is directly involved in
this situation.
Primary reason(s) for seeking services (please tick appropriate boxes):





Suspicious of infidelity
Affair Recovery
Advice on situation
Anger management
Loneliness





Counseling/Prior Treatment History
Tick if you have had:
When
Where
Result
Coping
Depression
Sexual concerns
Anxiety
Other ________________
 Counseling/Psychiatric
 Suicidal
thoughts/attempts
 Drug/alcohol treatment
 Self-help groups
Any additional information that would assist me in understanding your concerns or
problems:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
What are your goals for working with me?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
____________________________________________________________________________
If you need any more space for any of the questions please use the back of the sheet.
Where did you find me? (Please tick appropriate boxes):





Psychology Today
Dear Peggy
Social Media Site………………..
Google Search
Other search engine:…………..



Affair Recovery Directory
Referral _____________________
Other________________________
I understand:
 That any information discussed in coaching today will be kept 100% confidential.
 The session fees are due and payable at the beginning of the session.
 Coaching takes commitment and a changing of current patterns to work
effectively.
e-Signature:__________________________________Date:__________________________