Client Intake Form Name * First Name Last Name Gender * Male Female Email * Best Daytime Phone * (###) ### #### Home Phone (###) ### #### Cell Phone (###) ### #### May we leave information on your voicemail? * Yes No Preferred method of contact: * Cell Phone Home Phone Email Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Care Physician & Contact Did a Physician refer you to our program? Yes No Billing Information Name If someone other than yourself First Name Last Name Relationship to Client Billing Address If different than above Financially Responsible Individual: n/a Self How did you hear about our program? Which of the following best describes your goal for COACHING? * Eating Disorder Support Weight Management Emotional Eating Food Allergies Limited Food Acceptance Other If you answered "other", please indicate: In case of emergency, please notify: Name * First Name Last Name Home Phone (###) ### #### Best Daytime Phone * (###) ### #### Relationship to Patient: * Is there any specific information you'd like your coach to know before working with you? Thank you!
