Please answer each item carefully. The information you provide here is confidential, per the standards outlined in the Terms of Service of Center of Solutions, LLC.

This form must be completed and submited to Center of Solutions, LLC before you are able to begin consultation services with our staff.

First Name:

Last Name:

Nickname/Name you want to be called:

Age:

Email:

Does anyone else have access to your e-mail address?
Yes No

Street Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

When we call your home may we say who we are calling?
Yes No

When we call your work phone may we say who we are calling?
Yes No

When we call your cell/alternative phone may we say who we are calling?
Yes No

Primary Goals of Consultation

What are you unhappy about?

What do you think is the problem? (Please describe in detail)

What specific things do you want to see changed in this situation?

What steps have you taken to improve your situation?

Any other additional commetns or information you think the consultant should know about you or your situation?

Do you currently take any prescription drugs If so, please list.?

Do you use recreational drugs? Or use alcohol? If so, please list names and amount.

Relationship Status: Single High School Diploma Separated Divorced Committed Relationship

Living Arrangement: Alone With Spouse With Roommate With Boyfriend/Girlfriend/Partner With Other Family

Emergency Contact Information

Close friend/relative we may contact in case of a true emergency:

Relationship to you:

Emergency contact number:

Emergency contact City/State Zip:

Waht is your occupation?

Do you enjoy your job?
Yes No

If the Client fails to make the appointment time, the Client is still responsible for the coaching fee, unless 24 hour notice was given to reschedule the call. The Coach will make every effort to reschedule with the client.