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New Client Questionnaire

Please fill out and submit at least 48 hours before your Introductory Session.  Answers are confidential.

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New Client Questionnaire

HELP ME UNDERSTAND YOUR GOALS & CHALLENGES

 

All answers are confidential.  I do not share information with any other party without express permission.

 

Please submit the Questionnaire(s) AT LEAST 48 hours before our session, so I have time to review it before our meeting.

Personal Information

Your Information is never shared or sold!

 

Correct contact information is vital.  It is used here primarily for communicating about appointments:  questions, scheduling, appointment confirmations, rescheduling, and reminders.  Please include the client's contact information - 14 years old and older - to help make sure communication is open, up to date, and helping everyone arrive at sessions on time.

 

Please double-check that all personal information fields are completed & correct and read and check all the boxes to complete the Private Session Policies & Procedures Form submission.

 

The intake system has some limitations, and therefore, you will see fields that need a duplicate answer.  In these cases, please write out the correct answer again, instead of "same as above" type answers.  Other fields you need to read and answer that don't apply to you (put N/A).  Please fill out all fields correctly to complete the form.

 

Thank you for your patience!

 

 

NOTE TO PARENTS

Private Sessions for minor-aged children AND children NOT responsible for payment begins with You - the Parent.

 

Before I begin working with a dependent child, I have at least two sessions with at least one parent - the Introductory Session and a regular session.  During these sessions, we will get our bearings and chart our course together.

 

If you have not worked with me before and want me to start working with your child as soon as possible, please fill out this Questionnaire about yourself.  This is about you as the Client.  Parents need to understand what it is like to work with me and address any of their own challenges.  Working on themselves can help them to better support their child when they begin their own sessions.

 

If the main reason you are beginning sessions is to have me start working with your child, select "YES" on that question below.  You will receive an email that will give you further instructions.  Please read it before your Introductory Session.

 

Once at least one parent has completed their two sessions and we have determined when to begin the child, children 14 years of age & older, and the parent will each fill out and submit this Questionnaire at least 48 hours before the child's first session.

 

If you have already begun working with me as a client and would like me to work with your child, fill out a Questionnaire with your observations about your child.  If your child is 14 years or older, they need to submit the Questionnaire, too.  Both Questionnaires should be submitted 48 hours before the child's first session.

 

All answers are confidential.  I do not share information with any other party without express permission.

Question 4 of 34

Your Email:

Question 5 of 34

Your Name:

Question 6 of 34

I am answering as:

A

The Client - Party Responsible for Payment

B

The Parent - Party Responsible for Payment- sharing background information & observations about the client

C

The Client - NOT Responsible for Payment

Question 7 of 34

Name(s) of the Party Responsible for Payment:

Question 8 of 34

Email of the Party Responsible for Payment:  (please list the email connected to payment.)

Question 9 of 34

Cell Phone of the Party Responsible for Payment:

Question 10 of 34

Client's Name:

Question 11 of 34

Client's Date of Birth:

Question 12 of 34

Client's Age:

Question 13 of 34

Client's Gender:

A

Female

B

Male

C

I feel different than the biological parts with which I was born.

Question 14 of 34

If you answered "I feel different..." to the question above, please give me more detail to understand you better.

Question 15 of 34

Client email (14 and older, put N/A if younger):

Question 16 of 34

Client's Cell Phone (14 and older, put N/A if younger):

Question 17 of 34

How did you hear about me?

Question 18 of 34

Are you here primarily as a Parent looking into the possibility of me working with your child?

A

Yes

B

No

Please answer the following in as much detail as possible

_____________________

Question 20 of 34

What things are going in a positive direction in your/the Client's life?  What are you/the Client good at?

Question 21 of 34

What is your/the Client's #1 complaint?

Question 22 of 34

What other issues do you/the Client want to address?

Question 23 of 34

Please list any stress or anxiety symptoms you/the Client are experiencing (such as sleep problems, panic attacks, PTSD, obsessive-compulsive behaviors, depression, mood swings, feeling overwhelmed, addictions, etc.)

 

My list:

Question 24 of 34

Please describe any difficulties you/the Client are having in your relationships with yourself, your family, friends, or others?

Question 25 of 34

Are you/the Client able to speak openly about your needs?

A

Yes

B

No

C

Sometimes

Question 26 of 34

Are you/the Client able to care for your own emotional well being?

A

Yes

B

No

C

Sometimes

Question 27 of 34

Are you/the Client aware of any childhood traumas (including birth difficulties, adoption, deaths), accidents, family problems, or abusive experiences of any kind that may be having a lasting effect on you?

A

No

B

Yes

Question 28 of 34

If you answered "yes" to childhood trauma, please explain it here.

Question 29 of 34

Any other details you'd like to share to help me get to know you/the Client better?  (what grade are you in, single, married, divorced, kids, career, etc.)

Introductory Session

Details

Question 31 of 34

I want to do the Introductory Session over:

A

The Phone - you call me: 801.772.0176

B

NOT CURRENTLY AVAILABLE Skype - skype me: peggy.nazer (Skype calls require 24+ hours notification either through this form or via email. If we have not Skyped before, send a friend request 24+ hours before the session begins, so everything is ready before our appointment time. *Notification/Friend Request sent in less than 24 hours default to phone session.)

Question 32 of 34

THIS QUESTION ONLY APPLIES TO PARENT/CHILD APPOINTMENTS AFTER THE PARENT DOES THE INTRODUCTORY SESSION.  If the client is younger than 18 years old, the parent must be present for at least part of the child's first session.  Clients 14 years and older, please state your preference for having your parent present in your first session.  Parents, please state your preference here as well. *If this situation does not apply to you ( or your child is younger than 14), select N/A

A

Client- I want my parent there for the whole session

B

Client- I want my parent there but only for some of the session

C

Client- I do not have a preference on whether my parent is in the session or not

D

Client- I do not want my parent in the session

E

Parent- I want to be in for the whole session

F

Parent- I want to be in for part of the session

G

Parent- I do not have a preference on whether I am in the session or not

H

Parent- I do not want to be in the session

I

N/A

Question 33 of 34

THIS QUESTION ONLY APPLIES TO PARENT/CHILD APPOINTMENTS.  If you would like to give more detail about being, or not being, in a session with your parent (or with your child), please write it here.

Review Coaching Options

I have an online training & coaching program called Success Dynamics Academy and a Certified High-Performance Coaching program. 

Please take a few minutes and get acquainted with the different options available before our appointment so we can discuss which option(s) seem like the best fit for you.  Here are the pages to learn more:

Success Dynamics Academy - https://www.peggynazer.com/sda-home

High-Performance Coaching - https://www.peggynazer.com/chpc-group-coaching

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