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NEW CLIENT PROFILE

Big River Coaching

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Question 1 of 34

Name

Question 2 of 34

Date
(mm/dd/yyyy)

Question 3 of 34

Birth Date
  (mm/dd/yyyy)

Question 4 of 34

Address

Question 5 of 34

Phone Number

Question 6 of 34

Email

MEDICAL HISTORY

Details

Question 8 of 34

What information can you share that is important for our work together?

MEDICATION:

Please list all prescription and non-prescription medications that you are currently taking.

Question 10 of 34

Medication / Dosage / Prescribed for

HEALTH NETWORK

Please list doctors, psychologists, psychiatrists, assessment practitioners and any others, who are an important part of your present mental/physical/emotional health network.

Question 12 of 34

Name
Profession
Address
Phone

HEALTH AND WELLNESS

Habits

Question 14 of 34

Do you exercise regularly? What type of exercise?

Question 15 of 34

How would you assess your nutritional habits? Are there foods you crave or avoid?

Question 16 of 34

How often and what kind of caffeine do you consume?

Question 17 of 34

Is chemical use been an issue in your family’s history? Explain?

Question 18 of 34

Please describe sleep patterns or problems?

Question 19 of 34

List other healthy habits (yoga, meditation, etc):

Question 20 of 34

Anything else to share:

SCHOOL EXPERIENCE

Regarding the following academic experiences, what were your strengths? What was difficult for you? (e.g. reading, writing, math, sports, organization, socializing, attention, test taking, etc.)

Question 22 of 34

School Strengths

Question 23 of 34

Challenges

Question 24 of 34

Did you ever have a 504 Plan or IEP? Accommodations? Please Explain:

Question 25 of 34

COLLEGE/GRADUATE SCHOOL: Accommodations? Please explain:

EMPLOYMENT EXPERIENCE

Strengths / Challenges

Question 27 of 34

Strengths

Question 28 of 34

Challenges

Question 29 of 34

INTERESTS/PASSIONS/HOBBIES: (present or past)? Please share!

CURRENT STATUS

Share below

Question 31 of 34

What is working well for you? (any strategies, tools or beliefs that guide you, etc.)

Question 32 of 34

What is getting in your way? (habits or beliefs or commitments, etc)

Question 33 of 34

Is there anything you need or want to let go of that would make life feel easier?

Question 34 of 34

What is your hope for the future?

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