Holistic Coaching/ Counselling Intake Form

Holistic Coaching/ Counselling Intake Form

Your Practitioner: Annie Baxter
Client Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Marital Status
Email
example@example.com
Employment
Home Phone
Cell Phone
Preferred Method of Contact

E-mailHome PhoneCell Phone
Is the individual seeking counselling under 18?
If the primary individual seeking counselling/coaching is under 18 please fill in further information below. If you chose NO, please skip to medical history.
Full Name

Legal NamePrefered Name
Emergency Contact Information
Date of Birth

MonthDayYear
Date
Gender

FemaleMaleNon-binaryPrefer not to sayOther
If other, please comment below if you would like to identify your gender.
Please list Address if it is different from caregiver filling out this form.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who do they live with? (Parents, guardians, other relatives, foster care, etc.)
Siblings (Names and Ages)Is there anyone else living in your home? (Describe relationship and age)
Parent/Guardian Name
Phone Number Guardian
Please enter a valid phone number.
Parent/Guardian Name
Phone Number Guardian
Please enter a valid phone number.
Name

First NameLast Name
Medical History
Please check all the apply

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
Have you been convicted of drug related charges?

YesNo
Please explain the circumstances
Are you currently taking prescription medication?

YesNo
Have you had any surgeries in the past 5 years?

YesNo
Please specify:
Family history

AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal DiseaseOther
Mental Health History/Goals
Why you are seeking treatment?
What are you goals?
Any significant family changes recently (divorce, separation, death, etc.)?
Please share anything you feel is important for me to know in order to best support your child, including any emotional, behavioral, triggers, fears, social, family, school, or mental health challenges, recent life changes, trauma history, or goals you have for their growth and wellbeing.
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
Consent & Agreement Summary
Voluntary Participation:
I consent to participate in holistic coaching/counselling sessions voluntarily and understand this support is wellness-based and not a substitute for medical or psychological treatment.

Confidentiality & Privacy:
All sessions are confidential except when: There is risk of harm to self/others
Disclosure is required by law

I provide written consent: Online sessions are delivered through secure, HIPAA-compliant platforms (Psychology Today). While every effort is made to protect privacy, I understand no system is 100% secure.

Parental Consent (Youth Under 18):
In accordance with Alberta law, all legal guardians must provide consent. In joint custody, both guardians’ consent is required. Custody documentation may be requested to ensure compliance.

Parental/Guardian Consent for Coaching & Counselling

We, the legal guardians, consent to the child’s participation in wellness coaching and emotional support sessions. We understand these services provide support and skill-building but are not a replacement for therapy or legal advice.

The coach uses a trauma-informed, strengths-based approach to help the child with emotional regulation and resilience.

The coach/ counsellor, will share general progress with guardians while respecting the child’s privacy.

By signing, we agree to collaborate with the coach and support the child’s participation.

Technology & Safety:
I agree to attend online sessions in a private space. If technical issues arise, the practitioner may follow up via phone to ensure continuity of care.

Practitioner Statement:
I am a Registered Professional Counsellor (RPC-c, under supervision), Level 1 EFT practitioner, certified Life Coach, NLP and mindfulness-trained, and a Therapeutic Play Practitioner through RMPTI. I am committed to creating a safe, supportive, trauma-informed environment for each session.
For Online Youth Counselling sessions, please provide a number we can use to complete our session if our connection is lost at any point.
Please enter a valid phone number.
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Guardian signature

Clear
Guardian signature

Clear
Should be Empty:

Holistic Coaching/ Counselling Intake Form

Emergency Contact Information

Medical History

Mental Health History/Goals