Confidential Client Profile For your coach only. Please answer all questions as completely as you are willing. Do not hesitate to ask any questions which arise. Confidential Client Profile Step 1 of 4 25% Name* First Last Contact InformationMobile Phone*Home PhoneOther PhoneEmail* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country In an Emergency, Contact:*Emergency Contact Phone* Personal InformationGender* Male Female Birth Date* Date Format: MM slash DD slash YYYY Marital Status* Single Married/Domestic Partner Divorced Widowed Spouse/Partner NameYour Family & Close CirclePlease tell us with whom you live:*Please tell us about your significant other:*Please tell us about your parents:*Were you adopted?* Yes No You Said yes you were adopted. Do you know your birth parent(s)?How many members are in your immediate family?*Please tell us about your brothers and sisters:*Please tell us about your children:* Your HistoryHave you ever been hospitalized for medical or emotional reasons?* Yes No You said you have been hospitalized. What should we know about this?Have you ever been in an Accident or Other Traumatic Experience (e.g. Natural Disaster, War, Violent Crime, Etc.)?* Yes No You said yes. Please explain.Have you or your family members ever been arrested for and/or convicted of a felony?* Yes No You said yes. Please explain in detail, including dates and the disposition of the case.Have you or any of your family members ever been sexually molested or physically abused?* Yes No How do you still feel affected by this?Have you and/or any members of your immediate family declared bankruptcy?* Yes No You said yes regarding bankruptcy, who and what year?Has any family member or close friend died within the last year?* Yes No Please provide the name, relationship and how close you were. How many times have you moved in your life?*How many times have you moved in the last year?*Are you and/or any members of your immediate family currently in therapy and/or under the care of a doctor or other medical professional?* Yes No You said yes, please explain.Have you or any other member of your immediate family had difficulties with alcohol, drugs, or eating disorders?* Yes No If yes, please explain, including, if family member(s), who were they? How did this impact your life?Is there anything in your life that does not serve you that you might have difficulty giving up or letting go of?* Yes No You said yes. What is it?What in your life have you not been acknowledged for?*What are your strengths?*What are your weaknesses?*PhoneThis field is for validation purposes and should be left unchanged.
