Client Intake Form Cresenda Jones Client Intake FormPersonal InformationBackground & Life ContextFamily & RelationshipsSpiritual & Faith BackgroundMedical & Clinical HistoryCurrent SymptomsTelehealth Appointment PreferencesConsent & AgreementPersonal InformationLet’s start with the basics — tell us a little about you.First NameLast NameHome AddressAddress Line 1Address Line 2CityStateZip CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsEmailAgeDate of BirthSocial Security NumberGender Male Female Prefer Not to Answer OtherPlease specifyPlace of BirthCityStateCountryUnited StatesCanadaMexicoUnited KingdomIrelandAustraliaNew ZealandGermanyFranceSpainItalyNetherlandsBelgiumSwitzerlandAustriaSwedenNorwayDenmarkPortugalGreecePolandBrazilArgentinaColombiaPeruChileDominican RepublicJamaicaTrinidad and TobagoBahamasBarbadosGuyanaHaitiIndiaPakistanBangladeshPhilippinesVietnamChinaJapanSouth KoreaSingaporeMalaysiaIndonesiaThailandNigeriaGhanaKenyaSouth AfricaEgyptIsraelSaudi ArabiaUnited Arab EmiratesOtherBackContinueBackground & Life ContextA little context helps us understand where you’re coming from.How long have you lived in your current state?Military ServiceAre you or have you been in the Military Service? No YesBranchFromToEducation & OccupationEducation LevelSome High SchoolHigh School / GEDVocational / Trade SchoolSome CollegeAssociate's DegreeBachelor's DegreeMaster's DegreeDoctoral / Professional DegreeOtherCurrent OccupationEmployed ByWork AddressCityStateZip CodeDescribe your primary reason for coming to CoachingReferralWhom may I thank for referring you?Referrer's Address - Address Line 1Referrer's Address - Address Line 2Referrer's CityReferrer's StateReferrer's Zip CodeBackContinueFamily & RelationshipsYour relationships shape your story — this helps us walk alongside you.Current Marital Status Single Engaged Married Separated Divorced Co-Habitating Widowed OtherPlease specify Marriages or Significant Relationships Name Age Relationship Duration Occupation / School Grade Spouse's name (if applicable)Date MarriedChildren from this relationshipBackContinueSpiritual & Faith BackgroundShare what matters to your spirit, faith, and sense of meaning.Do you have a spiritual or faith background you'd like to share? No YesPlease shareWould you like your coaching to incorporate Christian faith principles? Yes No Not sure, I'd like to discussAny specific spiritual concerns or topics you'd like addressed?BackContinueSurgeriesHelp us understand the medical experiences that may shape your care.Any surgeries? No Yes Surgery Details Procedure Date Comments / Outcome Medical Diagnoses or DiseasesA clear health picture helps us support you with care.Any current medical diagnosis or diseases? No Yes Diagnosis Details Diagnosis Date Comments / Status Any current treatments or therapies for these conditions? No YesPlease describe current treatments or therapies.Family Impact of DiagnosisPrevious PsychotherapyAny previous psychotherapy? No Yes Previous Psychotherapy Details Date Started Date Completed Purpose of Therapy Therapist How helpful was it? HospitalizationsAny hospitalizations? No Yes Hospitalization Details Date Hospital Reason Current Medications Current Medications Medication Dose Prescribing Physician May I contact physician(s) to coordinate treatment? No YesBackContinueCurrent SymptomsCheck anything you've been experiencing - there's no pressure to be thorough.Symptoms currently experienced Headaches Fainting Spells/Dizziness No appetite/Overeating Stomach/Bowel disturbances Palpitations Tremors - shaking Poor sleep Nightmares/Night Terrors Unusual bodily sensations Sexual Problems Tired/No Energy Anxious Depressed Self-Esteem Issues Fears/Worries Inferiority feelings Panic Attacks Anger Issues Feeling Tense/Stressed Shy Poor Decision Making Lack Ambition or Interests Other Marital/Partner problems Parent/Child problems Unemployed/Work Issues Financial Problems Problems making/keeping friends Drinking problem Drug Abuse Gambling Sexual Addiction Excessive Shopping Previous Suicide Attempts Suicidal Ideas Visual Hallucinations Hearing Voices Disturbing thoughts or fears ManicPlease describe in detail those items checked above and for how long you have been experiencing each.BackContinueTelehealth Appointment PreferencesTell us when you’d prefer to connect for telehealth.Preferred Days & Times Monday AM Monday PM Tuesday AM Tuesday PM Wednesday AM Wednesday PM Thursday AM Thursday PM Friday AM Friday PM Saturday AM Saturday PMEmergency ContactEmergency Contact NameEmergency Contact RelationshipAny special accommodations needed?BackContinueConsent & AgreementPlease review and acknowledge the agreements before submitting. I have read and agree to the Terms and Conditions and Privacy Policy I have read and agree to the Terms and Conditions and Privacy Policy I consent to have this website store my submitted information so they can respond to my inquiryElectronic SignatureType your full nameDate Back Submit Form
