New Client Intake | Heart To Heart Coach

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First name*

Last name*

Email*

Phone*

Address

Birthday*

Month

Day

Year

Marital Status*

Partner Name

Children / Ages

How would you describe your relationship with your mother?*

How would you describe your relationship with your father?*

Health & Well-Being

Do you have any medical conditions we should be aware of?*

Are you currently taking medications?*

Are you working with a therapist or practitioner?*

Current Life Situation

What challenges are you currently experiencing?*

What areas of life feel most out of alignment?*

Why are you seeking support at this time?*

Goals & Intentions

What outcomes would you most like to achieve?*

What would success look like for you?*

Where You Are Right Now

Please rate each area from 1–10 (1 = lowest / most challenged, 10 = highest / most satisfied- no issues)

Emotional well-being *

Stress level*

Confidence / self-trust*

Overall life satisfaction*

Relationships*

Career / financial satisfaction*

Physical energy / vitality*

How ready do you feel to create change or transformation in your life right now?*

What do you feel has held you back most? (check all that apply)*

Fear or self-doubt

Past experiences

Lack of clarity

Time constraints

Financial stress

Relationships

Health or energy

Other

How did you hear about Enlightened Pathways?*

If Referral/Social Media/Event/ Please list.

I understand that coaching is not therapy or medical or mental health treatment, and I take full responsibility for my participation.

Signature - Signature (type your full name)*

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Enlightened Pathway Healing Center

Enlightened Pathways Healing Center

864 559-0249

melissa@ephcenter.com

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Enlightened Pathways Healing Center

Where Wholeness IS Remembered

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