Individual Intake Form - Cresenda Jones - Counselor, NLP Coach and Time Line Therapy® Master Practitioner

Individual Intake Form

Welcome!! To speed up the initial process, please fill out this form as completely as you can. All
information you provide will be kept confidential within the guidelines expressed in the Coaching
agreement. Thank you.

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Age

Date of Birth

Gender

Male

Female

Prefer Not to Answer

Place of Birth

City

State

Country

How long have you lived in your current state?

Are you or have you been in the Military Service?

Yes

Branch

From

Education

Current Occupation

Employed By

Address

City

State

Zip Code

Describe your primary reason for coming to Coaching:

Whom may I thank for referring you?

Family Information

Please list all of your marriages or significant relationships. (click "+" to add a new member)

Name

Numeric Field

Relationship

Occupation/(School/Grade)

Please list all of your Spouse’s marriages or significant relationships.(click "+" to add a new member)

Name of Spouse

Date Married

Children from this Relationship

Terminated

Medical and Psychotherapy History

Any Sugeries?

Yes

List all of your surgeries. (click "+" to add a new member)

Procedure

Date

Comments/Outcome

Any current medical diagnosis or diseases?

Yes

List your diagnoses. (click "+" to add a new entry)

Diagnosis

Date

Comments/Status

Any current treatments or therapies for these conditions?

Yes

Family Impact of Diagnosis:

Any previous psychotherapy?

Yes

List your previous psychotherapy sessions. (click "+" to add a new entry)

Date Started

Date Completed

Purpose of Therapy

Therapist

Any hospitalizations?

Yes

List your hospitalizations. (click "+" to add a new entry)

Date

Hospital

Reason

List out all your current medications. (click "+" to add a new entry)

Medication

Dose

Prescribing Physician

May I contact physician(s) to co-ordinate treatment?

Yes

Clinical Information

Please check all items that you have experienced in the last 6 months:

Please describe in detail those items checked above and for how long you have been experiencing each: