Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Gender

Male

Female

Other

Prefer not to say

Employment Status

Full Time

Part Time

Student

Retired

Home worker

Self Employed

Unemployed

Other

Name

First Name

Last Name

Phone *

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Gender

Male

Female

Other

Prefer not to say

Employment Status

Full time

Part time

Student

Retired

Home worker

Self Employed

Unemployed

Other

Relationship Status

Dating

Engaged

Married

Partnered

Divorced

Separated

Have either of you seen a therapist or coach before?

Yes

No

Anything else going on right now?

Stress

Work related issues

Family related issues

Relationship breakdown

Anxiousness

Lack of motivation

Self-esteem issues

Grief & Loss

Trouble with sleep

Health/medical issues

How severe is your situation?

We are highly distressed

We are moderately distressed

We are minimally distressed

We are not distressed

Emergency Contact Person's Name

First Name

Last Name

Emergency Contact Phone

Country

(###)

###

####

CLIENT CONSENT *

WE HAVE READ THE ABOVE INFORMATION CORRECTLY AND CAREFULLY AND UNDERSTAND :

Information about us will be collected for the purposes of the consultation session

All fees to be paid in full prior to first consultation unless otherwise agreed

The cancellation policy

There are circumstances (outlined above) under which the confidentiality of the information we provide may be broken

The Life Consultant does not provide emergency or after hours coverage and we know where to go to receive help if required

We can withdraw from consultation at any time without prejudicing any future consultation requests

The Life Consultant can withdraw from consultation at any time with verbal notice

CLIENT NAME (Partner 1) *

First Name

Last Name

CLIENT SIGNATURE *

I will submit this form electronically and by ticking this box agree to all the above terms and provide consent accordingly.

CLIENT NAME (Partner 2) *

First Name

Last Name

CLIENT SIGNATURE *

I will submit this form electronically and by ticking this box agree to all the above terms and provide consent accordingly.