Client Intake Form_Free

NEW CLIENT INTAKE FORM

Grief Recovery Coaching
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Email
example@example.com
Mobile Number

Area CodePhone Number
Home Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Occupation
Employer
Marital Status
Significant Other's Name

First NameLast Name
Names and Ages of Children:
GRIEF RECOVERY QUESTIONAIRE

If you are completing this form because of the death of a loved one, I offer my sincere condolences to you and your family. To get started, please complete The Grief Recovery Questionnaire. This is just a snap shot of how your life is at the moment and might give you a lot of clarity very quickly. Select a number from 1 to 10 next to each of the following areas of life. A number 10 means "Completely Satisfied" A number 1 means "Dissatisfied". Remember, this is your personal grief journey, so there are no right or wrong answers. Acknowledging the painful emotions that you feel allows you to give yourself permission to grieve, move forward, and decide to say yes to all that is waiting for you. I look forward to workkng with you. Please skip any question you do not feel comfortable answering.

ACCEPTANCE & FORGIVENESS

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

SUPPORT SYSTEMS

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

FAMILY & PARENTING

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

MAINTAINING A DAILY ROUTINE

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

SELF CARE

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

PHYSICAL ACTIVITY

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

SLEEP

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

CAREER/PROFESSION

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

VOLUNTEER WORK

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

PERSONAL TIME

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

BUDGET/FINANCES

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

SOCIAL

	1	2	3	4	5	6	7	8	9	10

1 is Dissatisfied, 10 is Completely Satisfied

GRIEF RECOVERY COACHING

GETTING TO KNOW YOU
We grieve because we loved. The emotions of grief are normal and natural responses to loss. Your thoughts, feelings, and behaviors are unique to you. What is not unique is the negative effects unresolved grief can have on you if not properly dealt with. Walking alongside of you as your coach, you will begin to embrace the future, using the appropriate tools along the way to accept and acknowledge the past. Please tell me a little about your current situation.
Are you or have you ever been in counseling or therapy?

YesNo
If yes, please explain.
What does your grief look like or feel like to you?
If you have lost a loved one, how would they want you to move forward?
What would you like grief coaching to do for you?
What, if any, are your concerns about coaching?
Rate the level of stress in your life on a scale of 1 to 10. (1=low and 10=high)
What are your primary stressors?
How would you love your life to look like 6 months - one year from now?
What else would you like me to know about you?
If you never felt the joy of loving someone, you would never feel the heartache associated with losing them. You have a broken heart, not a broken brain. While your feelings of grief and emotions are normal, your grief is totally unique to you. No one else had the relationship you had with your loved one. Always remember, acknowledging the many painful emotions that you feel allows you to give yourself permission to grieve, move forward, and decide to say yes to all that is waiting for you.

I look forward to working with you.

Laura Lawrence Wilcock
Laura Lawrence Wilcock, CPLC | www.northstarlifecoaching.com | laura@northstarlifecoaching.com | (203) 655-0800
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