New Client Questionnaire

Answer these questions so we can best help you
New Client Questionnaire
How are you feeling today?
Confirm email here
Eight characters minimum One lowercase letter One uppercase letter One number One special character
Select All Conditions You've Had Issue With
Marital Status

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

Please provide partner information if in a marital relationship
Please provide partner information if in a marital relationship
Confirm email here
Is your marriage/relationship in serious trouble?
Are you considering breaking up?
Are both of you committed to getting help for your marriage?
What is your spiritual orientation?
If you are a couple this is needed for your relationship assessment.

Let us know how you found us

Share what other search engine, friend or other source for this referral
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?
Have you been to our website at LifestyleTherapyCoach.com?
Are you thinking about hurting yourself or someone else?
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?
We don't prescribe medicine.
We do not offer in-person sessions. Are you OK with video conferencing?
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?
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?
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?
One must consider what resources they have available to invest in therapy and coaching
Use Shift+Tab to go back

Provide your information to access your offer

SHMS Speaker Offer Collector
First
Last