INITIAL INTERVIEW FORM FOR TELECOACHING SERVICES
Client Information Date: Name: Phone: Email: Address: City: State: Zip: May I have permission to mail to this address? Yes No Gender: Female Male Date of Birth: Others living at home: Employer: Occupation: How long have you worked there? How long in this occupation? Education: (List highest level of education) Primary Physician: Phone: List any significant health problems: Have you used a life coach before? Yes No If yes, when and with whom? Give a brief description of treatment: How were you referred to our office? Who may we thank for referring you? What factor(s) attracted you to our coaching service over others? Nearest relative other than spouse: Phone# Disclaimer: Telecoaching programs and services described herein are intended to provide individuals with a confidential and supportive process and structure through which they may achieve personal or professional goals more quickly and with more ease. Telecoaching is not a substitute for psychological counseling. This service is designed for education purposes only. In no way is it intended to be a means of psychological or medical diagnosis or treatment, nor should it be a substitute for regular or specialized psychological/medical care. Please consult a licensed health professional in your geographic area as needed. By submitting your credit card information, you are representing that you own that credit card or have the authority to use it.Dr. Turpeau makes no guarantees or warranties that coaching clients will reach any specific goals. The telecoachinng service is not intended for individuals who are actively contemplating suicide or suffering from a severe mental/emotional disorder. If this describes you, please call 911, contact your nearest hospital emergency room or call 1-800-SUICIDE (1-800-784-2433).
Phone:
How long have you worked there? How long in this occupation?
Primary Physician: Phone:
List any significant health problems:
Nearest relative other than spouse: Phone#
Disclaimer: Telecoaching programs and services described herein are intended to provide individuals with a confidential and supportive process and structure through which they may achieve personal or professional goals more quickly and with more ease. Telecoaching is not a substitute for psychological counseling. This service is designed for education purposes only. In no way is it intended to be a means of psychological or medical diagnosis or treatment, nor should it be a substitute for regular or specialized psychological/medical care. Please consult a licensed health professional in your geographic area as needed. By submitting your credit card information, you are representing that you own that credit card or have the authority to use it.Dr. Turpeau makes no guarantees or warranties that coaching clients will reach any specific goals. The telecoachinng service is not intended for individuals who are actively contemplating suicide or suffering from a severe mental/emotional disorder. If this describes you, please call 911, contact your nearest hospital emergency room or call 1-800-SUICIDE (1-800-784-2433).
