Client Form

This Client Form is for One-to-One Consultations. Please complete this form as much as possible, providing information on your challenges and which goals you would like to achieve. The more that you can tell us about yourself, the more we are able to support you. Please return this form prior to your first session to info@mjscoachingconsulting.com.

Confidentiality: Please note that all information will be kept strictly confidential except in the cases that we are legally obliged to report, such as a threat of injury to yourself or others.

*Mandatory fields

 

*First Name:


*Last Name:


*Email:


*Telephone Number:


*Skype ID:


*Today’s Date:


Address 1:


Address 2:


City:


Post Code/Zip:


*Country:


Date of Birth:


Emergency Contact Name and Number:




 

*List your challenges in order of priority: (e.g. psychological, emotional, blocks, repeating patterns, physical, financial, fears, phobias, addictions)

 













 

*Which goals would you like to achieve?

 







 

 

Do you have any potentially life threatening conditions? (e.g. heart trouble)

 





Lifestyle and history (including work and exercise):

 













Are there any genetic or inherited aspects or patterns to the issue? (included in parents, siblings, relatives)

 













Medications and supplements you are taking: (Include supplements, vitamins and prescribed drugs and dosages. If you were on long term medication in the past, please include it here)

 







Medical History: (Including operations and medical diagnosis)

 





What is your weekly alcohol intake? (in units)


What is your daily intake of water?


Is a doctor currently treating you? (Yes/No)


 

Please confirm yes or no that you agree to our Terms and Conditions and note that appointment cancellations with less than 48 hours notice incur the full service fee:


 

How did you hear about us?