Coaching/Mentoring Intake Form

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Do you have any history or current use of drugs and/or alcohol? If yes, describe:(Required)

Are you seeing a therapist at this time? If yes, briefly describe reason for seeing a therapist.(Required)

Do you take any medications? If yes, what?(Required)

Briefly describe your belief system, if any.(Required)

Is there anything else you would like me to know about you or your circumstances before we begin?(Required)

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Have you ever been coached before? If yes, please describe the experience:(Required)

Which of the following areas do you need help with?(Required)

Alcohol and Drugs

Negative Emotions (including Anger)

Anxiety and Fear

Depression and Sadness

Family Issues

Grief and Loss

Procrastination and Self Discipline

Relationships

Social Anxiety

Work and Career

Other, Not Listed

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Address
5204 S. Colony Blvd #200
The Colony, TX 75056
(Located inside Hope Community Fellowship Church)

Business Hours
Tue – Thur …… 10 am – 2 pm
Case management by appointment

Phone
(972) 445-7770

Email
pam@nextstepstc.org

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