Intake Form

Full Name

Age

Phone

Email Address

What makes you happy?

What concerns you?

What is your greatest accomplishment?

What have you been struggling with?

Do you have personal goals, and what are they?

What are your top 3 strengths?

What is something that has caused you disappointment?

I am optimistic I am optimistic Disagree Somewhat agree Agree Strongly agree

I am happy with my life I am happy with my life Disagree Somewhat agree Agree Strongly agree

I am happy with my health I am happy with my health Disagree Somewhat agree Agree Strongly agree

I am happy with my financial situation I am happy with my financial situation Disagree Somewhat agree Agree Strongly agree

I am happy with my social life I am happy with my social life Disagree Somewhat agree Agree Strongly agree

I feel good about my personal relationships I feel good about my personal relationships Disagree Somewhat agree Agree Strongly agree

Describe your general health

Describe any goals or desires you have yet to achieve

What has hampered you from achieving these goals?

What are your expectations of us working together?