INTAKE FORM/PERSONALITY PROFILE 4 -

Personality Profile 5

First Name

Last Name

Date of Birth

Please put in box below what gender you identify as:

What is your nationality?

What country do you presently reside in?

Marital Status

Single

Married

Divorced

Widowed

Do you consider yourself an Empath (highly sensitive or more of a Type A personality type? (Type A is considered less empathetic and sensitive and more of a go getter, competitive type)

Are you unemployed, self employed or employed? Please answer below. If employed or self employed, please describe below what you do for work?

Describe your fitness and activity level. What types of things do you do to keep active and exercise?

Describe your dietary lifestyle. What is your typical day to day diet is like?

Have you been diagnosed with any mental health conditions that we should be aware of? If so, please indicate below what it is and what treatment and/or medication protocols you are currently on if any.

Do you have any addictions? Please describe and elaborate how this is effecting your life and if you are doing anything to heal from it.

Have you had coaching or therapy before? If so, please indicate what you have taken and what you liked about it/how it helped you.

Do you have any physical health conditions? Please share below what you have and how that impacts your life

Describe your worklife and what you would like to see different (If you go to school, you can specify and describe below as well)

In your sessions, do you prefer to just talk about things ailing you in your life or to be coach/mentored or combination of both. If coaching/mentoring, is there anything holding you back from following the action steps and goals that will be given to help you move forward?

Do you have any hobbies or passions? If so, describe below what really brings you the greatest joys in life. Please elaborate if you are doing anything currently with your passions.

Is there anything else that you would like your Mentor/Coach to know for your sessions not already mentioned in this intake form?

Do you mind us using your email for the use of email marketing for You’ve Got a Friend or Emotional Health news? This could be any of the following, articles, newsletter, promotions, updates?

Yes

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