Coaching Intake Form | EmbodiedAuthenticity

Intake Form
Embodied Authenticity Coaching

This forms serves to inform me about anything that I would need to know about you in order to best support you in your growth before we connect over a call.

First Name

Last Name

Phone (e.g.+41765473829)

Please briefly describe the reason you are reaching out to me and what you wish to get out of the coaching session.

Please list any medications you are on and the condition that you are taking them for, below.

Do you have a history of chronic illness/fatigue/fibromyalgia or chronic/complex trauma (PTSD)? If yes, are you under someone’s care? Please list their name + name of their practise below

What have you tried therapeutically - what has worked/what has not worked for you? please list below.

Any past/current drug or alcohol use?

Is there anything else you’d like me to know?

[Note: Everything that you share within this form will be held in full confidentiality.] I understand that my anonymity will be protected and that all of my responses will be kept confidential.

I acknowledge that the coaching activities in which I will engage as part of the coaching container provided by Jonas Erb (Embodied Authenticity) have risks. By my participation in the coaching, I hereby assume all risks and all responsibility for any loss or damage. I voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify the Coaching Provider and their representatives, employees, and assigns from any and all claims, actions or losses which may arise out of the coaching. I agree to cooperate fully, to participate in all coaching procedures, and to comply with the plan of care as it is established. If I have any medical conditions, I have consulted with my physician to make sure that physical therapy is appropriate for me to participate in.

Thanks for filling out the intake form.
I am looking forward to getting to know you!

Intake Form Embodied Authenticity Coaching

Intake Form
Embodied Authenticity Coaching