Registration: Coaching

Linda Carroll-Barraud

MS, LMFT, BCC

Board Certified Life Coach

CLIENT INFORMATION

NAME *

First

Last

Date of Birth *

Address *

City *

State *

ZIP *

Home Phone

Cell Phone

Work Phone

Best for Messages

Email *

OK to discuss scheduling via email? *

YES
NO

OK to send receipts or statements via email? *

YES
NO

Marital Status *

Employment Status *

Gender

EMERGENCY CONTACT

Emergency Contact *

Emergency Phone *

Relationship to Client *

FEES FOR SERVICES

(Payment information appears at the end of this form.)

Number of Sessions *

Note: If necessary, travel expenditures will be charged separately.

NOTE: Coaching sessions must be used within one year of the date of purchase.

I understand that any remaining balance of fees and sessions will be forfeited after one year. *

Yes, I understand.

CANCELLATION POLICY

ALL SESSIONS ARE NON-TRANSFERABLE.
If you fail to cancel a scheduled appointment, this time cannot be used for another client and you will be billed for the entire cost of your missed appointment. A full session is charged for missed appointments or cancellations with less than 24 hour notice unless due to illness or emergency. Thank you for your cooperation in this matter.

LIMITS OF CONFIDENTIALITY

Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:

Duty to Warn and Protect / when a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Abuse of Children and Vulnerable Adults / if a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.

Prenatal Exposure to Controlled Substances / mental health care professional are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

Minors/Guardianship / parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

I agree to the above limits of confidentiality and understand their meanings and ramifications.

Client Signature *

Clear Signature

(client's parent/guardian if under 18)

Date *

INTAKE FORM

Please provide the following information and answer the questions below. Please note: Information you provide here is protected as confidential information.

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? *

NO
YES

↳ If YES, previous therapist/practitioner:

Are you currently taking any prescription medication? *

NO
YES

↳ If YES, please list:

Have you ever been prescribed psychiatric medication? *

NO
YES

↳ If YES, please list and provide dates:

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

1. How would you rate your current physical health? (Select one) *

2. How would you rate your current sleeping habits? (Select one) *

3. How many times per week do you generally exercise?

↳ What types of exercise to you participate in?

4. Please list any difficulties you experience with your appetite or eating patterns:

5. Are you currently experiencing any chronic pain? *

NO
YES

↳ If yes, please explain:

6. Are you currently in a romantic relationship? *

NO
YES

↳ If yes, for how long?

↳ On a scale of 1-10, how would you rate your relationship?

7. What significant life changes or stressful events have you experienced recently?

FAMILY MENTAL HEALTH HISTORY

Alcohol/substance abuse *

YES
NO

List Family Member

First

Last

Anxiety *

YES
NO

List Family Member

First

Last

Depression *

YES
NO

List Family Member

First

Last

ADDITIONAL INFORMATION

1. Are you currently employed? *

NO
YES

↳ If yes, what is your current employment situation?

↳ Do you enjoy your work? Is there anything stressful about your current work?

2. Do you consider yourself to be spiritual or religious? *

NO
YES

↳ If yes, please describe your faith or belief:

3. What do you consider to be some of your strengths? *

4. What do you consider to be some of your weaknesses?

5. What would you like to accomplish out of your time in therapy? *

6. If coaching was successful for you, describe three things that would be different in your life. *

Who referred you to Linda?

How did you hear about Linda's work?

Number of Sessions *

Your Payment *

Card Number

Expiration Date

Security Code

Card Holder Name

Please complete the form in full. Fields marked with a * red asterisk are required.

Linda Carroll-Barraud

MS, LMFT, BCC

CLIENT INFORMATION

EMERGENCY CONTACT

FEES FOR SERVICES

CANCELLATION POLICY

LIMITS OF CONFIDENTIALITY

INTAKE FORM

When you are finished, click the Button below. Please be patient as we register the transaction.