A Centred Mind

Client Intake Form

Please complete this form as accurately as possible. The information provided helps your coach understand your circumstances, prepare for your sessions, and offer support that meets you where you are.

Section 1 of 17: Who Is Completing This Form?6%

Who Is Completing This Form?

Please let us know who is completing this intake form.

Completion Type*

I am completing this form for myself

Parent or legal guardian completing for a minor

Carer or support person assisting the client

Authorised representative completing on behalf of the client

Representative Full Name

Relationship to Client

Contact Number

Email Address

Authority to Provide Information

I confirm I have authority to provide this information on behalf of the client.

Authority to Receive Communication

I confirm I have authority to receive communication about the client.

Supporting Notes

I confirm that I am authorised to provide this information on behalf of the client.*