Welcome!

Please fill out this intake form to get started.
Welcome to the Client Intake Form, a series of questions about you and your relationship. Answering this form will help me get to know you better and will also give you time to reflect on your situation, too. I am so happy you are here and am honoured to support you on your journey!

The starred questions (with a *) are mandatory but the rest are optional. Please answer according to your comfort level, keeping in mind that the more information you share, the better I will be able to understand your situation and be equipped to help you and your spouse.

Please be assured that all information shared here, and on the call, is 100% confidential.
1. Name*
2. Email*
3. Phone
4. Emergency contact information (Name, relationship, phone number)
5. Relationship Status *
6. How long have you been together?
7. How long have you been married? (if applicable)
8. If applicable, children's names and ages (with current spouse)
9. Are you in a blended family? If yes, please answer q. 10-12, if applicable)
10. If applicable, children's names and ages (with previous partner) 
11. .If applicable, children's names and ages (partner brought into the relationship)
12. If applicable, what is your custody situation?
13. What is your job/profession/role?
14. How happy are you in your job/profession/role?
15, What would you llike to change with coaching?*
16. Have you had any past experience with coaching or counseling, individually or together? If so, please describe. Was there anything about that experience that did and/or didn't work well for you?
17. Which of the following are behaviours you sometimes demonstrate when things are challenging (check all that apply)
18. If applicable, which of these are behaviours your partner sometimes demonstrates when things are challenging (check all that apply)
19. What is the best part of your relationship?*
20. What is the best thing about your partner?*
21. What would you like to see more of in your relationship?*
22. What gets in the way of having this?
23. What was your parents' relationship like?
24. Please briefly describe your major past relationships and why they ended.
25. Are you currently on any medication for mental health?
26. How would you describe your stress level on a scale of 1-5?
27. What goals do you have for yourself? How confident are you in reaching them?
28. What area of your life is going the best right now? Please explain. *
29. What area of your life is most concerning right now for you? Please explain. *
30. What is your faith tradition, if any, and how important is your faith to you?