CLIENT QUESTIONNAIRE Tell me about you!Name* First Last Date Prepared:* Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Evening Phone*Cell Phone*Email* Date of Birth:* MM DD YYYY Occupation:*Years in Position?*Employer Name:*Nature of Business/Position:*Name of Other Party(ies)*Children's Names/Ages:*Other Relevant/Interesting Facts About You:*THE INITIAL INTAKE FOCUS FORMBy completing this Focus portion of the form, you will be highlighting key pieces of information in preparation for your first consultation. The process of putting it in writing facilitates clarity and better structures your scheduled time. I, too, can become better oriented to your situation as we start our working relationship. If time permits, it is helpful to complete and submit this form to me prior to our first meeting.1. Please describe in two or three sentences the key challenge(s) you face:*e.g working relationship, personal relationship, medical condition, workload, career direction, time management, etc.2. How long has this been going on for you?*If "Other" please describe in the space available30 days or less90 days or less6 months or less1 year or lessmore than one year3. Who else is involved in your situation and what is their relationship to you:*4. What would you like to see happen in order to resolve this situation:*5. What efforts have you undertaken to date to try to resolve this challenge?*6. How much are you willing to invest in resolving this situation?*e.g. time, activities, money7. What timeframe do you have in mind for getting this challenge resolved?*8. What is your goal for seeking services?*9. On a scale of 1 to 10, with “10” being the “BEST” and “1” being the “WORST”, answer the following questions and check the number for your response, e.g. 7: A: Where are you today on this scale?*12345678910B: Where were you six months ago on this scale?*12345678910C: What about one year ago?*12345678910
