Client History Form for Authentic Insights "*" indicates required fields First nameLast nameEmail MobileEthinicityCountry of birthGenderSexual orientationHighest level of educationCurrent occupationBirthdate MM slash DD slash YYYY AgePlease enter a number from 13 to 150.Name of Spouse/Guardian if under 18 First Last PERSONAL INFORMATION Areas of special interest or hobbiesWhat do you do for yourself as self-care activities?Do you use any of the following? Alcohol Caffeine Nicotine Other Select AllIf yes, how much per day?Prescription drugs taken:Over the counter drugs taken:Medical historyPlease share anything you feel may be relevantList any recent health or physical changes within the last year:Martial status (more than one answer may apply) Single Engaged Separated Widowed Partnered Married Divorcing Divorced Dating Common Law Other What are some of the things you would liek to speak to your Intuitive Coach about: Anxiety Decision Making Expressing Feelings Grief Pet Loss Relationship Sexuality Spirituality Body image Distractability Fatigue Irritability Personality Religion Shame Stress Communication Eating Concerns Finances Loneliness Regret Self Esteem Sleeping Worry Other Any additional information that would assist your Intuitive Coach in understanding your concerns or problemsIn case of an Emergency, do you give permission for us to contact someone for you?* Yes No Please see below for the contact informationEmergency Contact Name First Last Relationship to youThier Phone
