Intake Form

Welcome to Ascend Wellness

Please complete this intake form and submit it before our initial session. The intention is to consider what it is you are seeking, and how you can get the most out of this transformative experience.

Todays Date

Name

Age

Address

Phone

Occupation

Next of Kin

Contact number

What brings you to coaching therapy at this point in your life?

Is there a challenge, pattern, or area in your life where you feel stuck or disconnected?

What would meaningful change look or feel like for you over the next few months?

Have you previously explored therapy, coaching, or other healing modalities? What did you find helpful or unhelpful?

Please list a history of any surgeries, major illnesses, conditions, injuries, medication or anything else which I should be aware of when working with your mind and body.

How did you find out about Coaching Therapy? Is there anything in particular that you would like to receive?

Is there anything else you would like me to know before we begin our journey together?

By checking this box and submitting this form you agree to Ascend Wellness processing and storing my data in accordance with The Data Protection Act 2018. For more information please view our GDPR Policy.