Client Intake | Jay Cataldo Life Coaching

Date:

Name:

Occupation:

Home Address:

City:

State:

Zip Code:

Landline #:

Cell #:

Email Address:

Is it okay to leave messages at all numbers and emails? If not Why?:

Date of Birth:

Age:

Education:

Health in General:

Do you have any sleep problems:

Do you have any phobias?:

Have you ever been diagnosed with, hospitalized or treated for a mental health condition?:

If so please describe:

Do you have any past or current problems with ADD/ADHD, addictions, depression or anxiety?:

If so please describe:

Are you currently undergoing therapy?:

If so please describe:

Are you taking any medications?:

If so please describe:

Are you usually on time or running late?:

Do you exercise regulary?:

If so please describe:

Please describe your eating habits:

What hobbies or sports do you enjoy?:

What do you do for fun?:

What do you believe you have to contribute to the world?:

Is there a secret passion in your life?:

If so, what is it?:

What do you believe in?(family, God, self etc.):

If you knew you could not fail, what would you attempt to do?:

Other information you would like me to know?:

How did you hear about my coaching services? If you used google, yahoo or bing, please tell me what search term you typed in:

What are your specific goals for our sessions?:

How long do you expect it to take to reach these goals?:

What would you like to focus on first?:

What will you gain from achieving these goals?(be specific):

How would you know for sure that you have achieved your goals?:

Would there be any downside to eliminating these issues?:

What is reaching this outcome worth to you?:

Do the benefits outweigh the perceived costs? :

What do you think has stopped you in the past from overcoming them?:

Describe what your perfect life would look like:

What dreams do you have?:

What dreams have you given up on?:

What part of your life, career, or relationship is working best right now?:

What part of your life, career, or relationship is working least right now?:

What are the obstacles that are keeping you from living the life you want to have? :

CANCELLATION POLICY: My time is my income and my hours are by appointment. Your appointment time is reserved exclusively for you. Please arrive (or be online) promptly to obtain your full session. I require 24 hours notice for cancellations. Even then, it is unlikely I can fill your time slot. Unless cancelled, you are financially responsible for the time reserved. If you must cancel or reschedule an appointment due to an emergency, please notify me as soon as possible. Thank you for your consideration.

PREPAID VISITS: The same policy applies to prepaid visits. Except in an emergency, 24-hours notice is required. Failure to keep your appointment or short-notice cancellation will result in the forfeiture of a prepaid visit. All prepaid visits will expire three months after purchase.

CONFIDENTIALITY: Anything you discuss with me is held in strict confidence. I will not release any of your information to anyone without a written authorization from you, except as provided for by law. You have a right to be allowed access to my written record about you.

CLIENT CONSENT & RELEASE: I am over the age of 18 years old and hereby agree, voluntarily and freely, to receive information from Jay Cataldo. I understand that Jay Cataldo is not a licensed health care practitioner and that the information I will be receiving is not legal, therapeutic or personal advice and can not be considered as such. This information cannot replace or substitute for the services of trained professionals in any field including, but not limited to, psychological, financial, medical or legal matters. I understand that I should consult a medical professional concerning any symptoms that may require medical attention. I also promise to disclose any prior or existing or mental health condition to Jay Cataldo. I further release both Jay Cataldo and Relate Right Inc. from being held liable in any manner whatsoever stemming from my use of the information I will be learning, including, but not limited to, economic loss, injury, illness, harmful effects, emotional distress or death. I assume full responsibility for the consequences of my own decisions and actions.

I declare that I have read this consent and release, and that I fully understand and agree to its terms.

Check here to confirm you accept these terms.