Nourishing Truth by Clara Belle Kelly Client Intake Form Name * First Name Last Name Date of Birth MM DD YYYY Age Gender Personal Pronouns Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email Can I leave messages and send emails relating to your appointment? Please select Yes No ** Please answer the questions below. What is your relationship status? * Rate your relationship on a scale of 1 - 10. * Do you have children, if so, how many? * What is your religious or spiritual affiliation? * Have you had coaching before? If yes, please detail. * Is there anything about your family history, personal experience or life events you want to share? * Are you having current thoughts of, or are you thinking about, hurting yourself or another person? * Please select Yes No Current Employment/ Job * Rate your job satisfaction on a scale 1-70 * Please list any stressors in your life * What would you like to focus on in the coaching sessions? * Are there any specific areas you would like to develop? e.g Relationship to food, control/confusion with food, connection with your body, relationship with self etc * Is there anything else that you want to share? * Do you have any questions about our coaching sessions? * Please tick that you acknowledge the following * I have read and understood the Terms & Conditions of working with Clara Kelly and accept the Privacy Policy (available on clarabellekelly.com). I acknowledge that as a coach, Clara Belle Kelly is obligated to report any instances of illegal activity disclosed during coaching sessions in accordance with applicable laws and regulations. I understand that coaching sessions are conducted with strict confidentiality, with exception to legal mandates, supervisory oversight, and in instances where there is a foreseeable risk of harm or safety concerns. I acknowledge that Clara Kelly is not a licensed medical professional and that coaching services provided are not intended to replace or substitute for medical or psychological treatment. Should I require medical or psychological assistance, I understand that it is my responsibility to seek guidance from a qualified healthcare provider. Signature First Name Last Name Date MM DD YYYY Thank you! I will be in touch shortly.
