Confidential Client Information Form

Thank you for booking coaching with Leah Steele. In order to fully assess and support you in your sessions, please ensure this form is completed as fully and accurately as possible; the information you provide will be reviewed with you in your next session.

The information you provide will remain confidential within Searching for Serenity and will be stored securely on your client file.

If you have any questions, please contact Leah directly via email hello@searchingforserenity.co.uk or via WhatsApp on 07858135667.

Name

First Name

Last Name

Gender

Male

Female

Transgender

Other not listed

Pronouns

Date Of Birth

YYYY

Home Address

Phone

Country

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Relationship

Emergency Contact Phone

(###)

###

####

Emergency Contact Email

General Practitioner (GP) Name

Name of GP Surgery

GP Surgery Address

GP Surgery Telephone Number

(###)

###

####

Are you currently taking any prescribed any medications?

If yes, please provide more information

Do you have any medical conditions which may impact you or our sessions?

If yes, please provide more information

Have you ever had coaching or counselling before?

I have read and agree to abide by the client contract sent with this form

Yes