New Client Info Form

I am filling this form out for:

Myself

Client Name*

First Last

Referred by

Address (Please include APT, Suite, etc.)*

Street Address City State ZIP Code

Email (Main)*

Email (Secondary)

Phone (Day)*

Phone (Evening)

Age*

Date of Birth*

MM

DD

YYYY

Marital Status

Single
Partner
Married
Divorced

Name of Spouse, Partner or Parent

Do you have children?

Yes
No

Please include sex and ages of children

If that person calls ADDRC, may we share information about your progress?

Yes
No

Your Education Level Completed

Choose from the drop down box

Your Occupation

Your Employer or School

About your doctor and/or therapist

Doctor/Therapist 1 Name

Doctor/Therapist 1 Phone

May we contact Doctor/Therapist 1 to discuss your progress

Yes
No

Doctor/Therapist 2 Name

Doctor/Therapist 2 Phone

May we contact Doctor/Therapist 2 to discuss your progress

Yes
No

Current Diagnosis (If applicable)

Current relevant medications

Medication 1 including dosage/timing

Medication 2 including dosage/timing

Medication 3 including dosage/timing

Medication 4 including dosage/timing

Medication 5 including dosage/timing

Medication 6 including dosage/timing

I need more space for my medications

Yes

Additional medications

Are there any issues we should know about, to help us do a better job of working with you?

Please briefly list your major current concern(s): Why you’re here and what you’d like to gain.

COMMITMENT TO THE COACHING PROCESS:

I understand that successful Coaching requires a personal commitment of time, money and energy. I realize that to be effective, Coaching requires my honesty, openness and effort.
I understand that the information provided by The ADD Resource Center and its Coaches is not medical, psychological, legal or financial, and must not be used in place of the consultation and advice of a physician, therapist or other healthcare provider, accountant, attorney, etc.
I understand that Coaching is an adjunct to, and not a replacement for, appropriate medical or therapeutic interventions, and that Coaching is not intended to diagnose, treat, cure or prevent any problem or disability.
I agree to pay the agreed upon fee per session, whether the session is in-person or by phone, and that payment is due at each session or by prepayment. I understand there is an additional fee when sessions are held at my office or home. If I cancel less than 36 hours prior to a scheduled session, I am obligated to pay for that session in full, unless a make-up session (in person or via phone) can be arranged within 3 days of the scheduled appointment.
I agree that checks returned unpaid by the bank are subject to a $20 fee.

I have read and agree to the Committment to the Coaching Process in the box above.*

yes

Email

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