Client Intake Form

Please fill our Intake form

Name

Birthday

Gender

Phone Number

Occupation

Address

Marital Status

Are you taking Medication

Yes No

If Yes, please explain

What is your current mental and emotional state? Do you have any traumas you would like to share with me?

What is your current stress level? How do you manage or work with stress in your life?

Are you coachable? What are your goals for personal growth and development?

Can you describe what you are hoping to gain from working with me?

What is your relationship with plant medicine and entheogens?

What personal strengths or resources do you have in your life that may support you during this process?

Are there any specific goals or areas of your life that you would like to focus on while working together?

How do you typically care for youself?

What are your expectations from this coaching relationship?