New Client Questionnaire

Welcome to Lifestyle Therapy & Coaching!

Take a few minutes to help us understand how we can help you. This form is a part of our intake process. It is designed to tell us more about you so we can assess how to best help you. This form is also a tool to help you clarify your goals.

Our practice is primarily focused on helping heterosexual couples. If you are in a marital relationship your partner's contact information will be needed so they can also receive the assessment login.

After you complete this form you will be able to make your appointment for your initial session. During this session you'll get to share what is going on and what you want help accomplishing.

Name
Name
First
Last
Confirm email here
Marital Status

Answer if you are married, living together, engaged or dating

Please provide partner information if in a marital relationship
Please provide partner information if in a marital relationship
Confirm email here
Is your marriage/relationship in serious trouble?
Are you considering breaking up?
What is your spiritual orientation?
If you are a couple this is needed for your relationship assessment.

Let us know how you found us

Share what other search engine, friend or other source for this referral
What words did you use to search on?
Are you just now looking for a therapist or did you start looking a while back and just decided it was time to get help?
Have you been to our website at LifestyleTherapyCoach.com?
Are you thinking about hurting yourself or someone else?
If you are thinking of hurting yourself or someone else you should call 911 and let them know so that you can get assistance right away.
Are you looking for us to prescribe medicine for you?
We don't prescribe medicine.
We do not offer in-person sessions. Are you OK with video conferencing?
We have found that video conferencing is just as effective as face-to-face. We utilize Zoom primarily.
Are you ready to do something different?
Just making sure you are a serious client in a position to put your all into this process.
Are you prepared to spend the time needed to work on your goals?
Do you have time for this in your weekly routine and are you willing to focus on this for extended amount of time?
Are you prepared to cover fees uncovered by insurance?
Some of our programs are cash pay only. Others you can use your insurance. You are responsible for all charges whether your insurance pays or not.
Once you submit this form you will be redirected to my scheduling link. You will also receive an email with that link.