Client Intake – Sizzling Hot Marriage

First Name

Last Name

Confirm Email

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Mobile Phone

What is the best time you can be reached by phone?

Refer to me as (Him/Her)

Please indicate the pronoun you would like to be referred as

City

State

Country

Tme Zone

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Eight characters minimum One lowercase letter One uppercase letter One number One special character

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What are you seeking help with? What's the problem you are facing?

Has something happened to help you make your decision to get counseling now? Please share.

Marital Status

Married

Dating/Engaged

Living Together

Not in a relationship

Are you seeking help alone or are you doing this with your partner?

Alone

Partner

Heterosexual?

Yes

Please indicate if you are in a heterosexual relationship

Answer if you are married, living together, engaged or dating

Partner Name

Please provide partner information if in a marital relationship

Partner Email

Please provide partner information if in a marital relationship

Confirm Partner Email

Confirm email here

Partner Cell Phone

Have you made your spouse/partner aware they will be receiving an invitation to complete this questionnaire?

Yes

Make sure you let your spouse know they will be receiving an email invitation to complete this form.

Is your marriage/relationship in serious trouble?

Yes

Are you considering breaking up?

Are both of you committed to getting help for your marriage?

Yes

What is your spiritual orientation?

If you are a couple this is needed for your relationship assessment.

Let us know how you found us

How did you hear about us?

Why did you pick us?

Where did you get our number to make this call?

Other source

Share what other search engine, friend or other source for this referral

What was your search term?

What words did you use to search on?

Are you just now looking for a therapist or did you start looking a while back and just decided it was time to get help?

Just started looking

Started looking a while back

How long ago did you first start looking?

Have you been to our website at LifestyleTherapyCoach.com?

Yes

Are you thinking about hurting yourself or someone else?

Yes

If you are thinking of hurting yourself or someone else you should call 911 and let them know so that you can get assistance right away.

Are you looking for us to prescribe medicine for you?

Yes

We don't prescribe medicine.

We do not offer in-person sessions. Are you OK with video conferencing?

Yes

We have found that video conferencing is just as effective as face-to-face. We utilize Zoom primarily.

Are you ready to do something different?

Very Ready

Mostly Ready

Not Ready

Just making sure you are a serious client in a position to put your all into this process.

Are you prepared to spend the time needed to work on your goals?

Very Prepared

Mostly Prepared

Not Prepared

Do you have time for this in your weekly routine and are you willing to focus on this for extended amount of time?

Are you prepared to cover the cost of these services?

Very Prepared

Mostly Prepared

Not Prepared

One must consider what resources they have available to invest in therapy and coaching

While we do not accept insurance we have affordable options for you. We will discuss these options during your free sizzle evaluation.

Who do you watch or listen to about relationships? Which platforms do you listen to them?

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Welcome!

Answer these questions so we can best help you

Answer if you are married, living together, engaged or dating

Let us know how you found us

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