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.)?
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
Client Consent: I, the undersigned, consent to participate in Holistic Coaching & Counselling session. I understand and agree to the following: Voluntary Participation: I am participating in this session voluntarily and of my own free will.

-Confidentiality: I understand that all information shared during the session will be kept confidential, with the following exceptions: (1) if I pose a danger to myself or others, (2) if required by law, (3) with my written consent.

-Limits of holistic practices and coaching: I understand that this is not a substitute for medical or psychological treatment. If I have a medical or psychological condition, I agree to consult with an appropriate healthcare professional.

Your privacy and confidentiality are of utmost importance to us, and we adhere to strict HIPAA regulations to protect your personal health information. We offer e-counseling services through secure, HIPAA-compliant platforms such as Psychology Today and Zoom. All online sessions are confidential, and no session will be recorded or shared without your explicit consent. It is important to choose a quiet, private space for your online sessions. While we strive to ensure the security of all communications, please be aware that no system can be completely secure, and there are potential risks, including breaches of confidentiality. In the event of a technical issue or disconnection, we will complete the session via phone call to ensure continuity of care. By participating in online counseling, you acknowledge these risks and agree to proceed with the understanding that all reasonable measures are taken to protect your privacy.

In Alberta, parental consent is required for counseling youth under 18. In cases of divorce or separation, the consent needed depends on the custody arrangement: sole custody requires consent from the custodial parent, while joint custody typically requires consent from both parents. We will verify custody arrangements to ensure compliance with legal requirements.Our goal is to support your child while adhering to these guidelines and ensuring all necessary consents are obtained.

-Practitioners Statement: I, the undersigned, am a Registered Professional Counsellor RPC-c, under supervision. Iam certified in ThetaHealing, level 1 EFT, certified Life Coach, mindfulness and NLP, and am dedicated to providing a safe and supportive environment. I will guide and support you throughout the process and ensure your well-being during and after the session. I am undertaking level 2 EFT, and Play therapy pratitioner training.

Practitioner's Signature:Annie Norris-Baxter
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Holistic Coaching/ Counselling Intake Form

Emergency Contact Information

Medical History

Mental Health History/Goals