Intake Form

DivorceN’Me Founder

Ms. DeAnna Williams,

Professional Life Coach For Divorced Women & Men

127 Custer Avenue Evanston, Illinois 60202

Telephone: (847)347-1675

email: t.de66@yahoo.com

Website divorcenme.org

DIVORCE N’ ME INTAKE FORM

Please provide the following information. Information you provide is

confidential, just like therapy. Please print out this form and bring it to your

first session or allow yourself 15 minutes prior to your appointment to

complete the form in the office.

Date(required)

Name (First) (Middle Name) (Last Name) (required)

Name of parent/guardian (First) (Middle Name ) (Last Name) (if you are a minor):

Birth Date:(required)

Age: (required)

Gender: Male/ Female (required)

Male Female

Address: (Street and Number) (City) (State) (Zip) (required)

Home Phone Number(required)

May we leave a message?(required)

Yes No

Cell/Other Phone: (required)

May we leave a message?(required)

Yes No

May we email you? *Please be aware that email might not be confidential.(required)

Yes No

Email(required)

If married, name of spouse:

Name of Children and ages:

Personal/Professional Goals:What are the biggest changes you want to make in your life in the next 3 months? (required)

Personal/ Professional Goals: What are the biggest changes you want to make in your life over the next 3 years? (required)

What do you most want to achieve for yourself in your life/career? (required)

3: (required)

What would you say have been your 3 greatest accomplishments to date?(required)

What are the restraining forces keeping you from achieving these? (required)

2: (required)

What would you say have been your 3 greatest accomplishments to date?

1: (required)

2: (required)

3: (required)

What do you expect to achieve in life as a result of hiring me as your life coach?

What is the hardest thing in your life that you have had to overcome?

What major transitions or life changes have you had in the past two years?(Example: Entering or approaching a different age, a new or different relationship, job role, residence, a change in children’s ages/stages, etc.) 1.

Who are or have been your major role models? Why?

Have you worked with a coach before or a similar one-on-one adult

relationship (e.g. tennis coach, piano teacher, and therapist)? If so, what

worked well for you and what did not work in the relationship(s)?

1: (required)

Who will be supporting you through this process?

1: (required)

Your Life Story / History:

What would you like to share with me in session?

1: (required)

On a scale of 1 to 10 with 10 high, rate the quality of your life today.

List five things that you’re personally tolerating or putting up within your life

at present. (Examples: information you can’t find, rude friends, job

dissatisfaction, cranky people in your life, etc.)

1: (required)

In a typical week, what do you spend a great amount of time doing?

1: (required)

What are your primary stressors? (What stresses you out?)

1: (required)

On a scale of 1 to 10, 10 high, rate the amount of stress in your life right

now.

Life Changes:

Please list any changes you would like to make in the following areas:

1: (required)

Family:

1: (required)

Money / Financial Situation:

1: (required)

Career / Business life:

1: (required)

Service / Personal Character:

1: (required)

Relationships:

1: (required)

Friends:

1: (required)

Living Space / Home:

1: (required)

Personal Growth / Learning:

1: (required)

Health / Self Care:

1: (required)

Creativity:

1: (required)

Play / Leisure time:

1: (required)

Leisure: Hobbies:

1: (required)

What do you spend most of your leisure time doing?

1: (required)

Life Strategy Agreement

Date: (required)

Name: (required)

Our sessions are conducted in any of the formats such as over the phone, in

the office, or virtual (Skype, Tango, Facetime, etc.).

The cell number is (847) 347-1675. Missing or rescheduling sessions is

strongly discouraged. If an unforeseen event does require you to reschedule,

I must be notified 24 hours prior to the scheduled session. Please remember

that not completing, or partially completing your assignments is not a reason

to reschedule. If assignments are not complete, it is very important that we

thereby forfeited.

Divorce N’ Me Disclaimer of Liability: Client hereby employs Divorce N’ Me for

the purpose of supporting the Client with respect to Client’s self-awareness,

vision and goals, and strategic plans, has experience in such matters and

agrees to render such coaching services for the purpose of life coaching and

strategizing.

I have read and agreed to the Policies and Disclaimer of Liability.

Online Client’s Signature

Note: By printing your full name constitutes as to you having agreed that this

is your affixed online signature in order to enter into this therapy session(s).

Divorce N’ Me Signature

Once you have completed this form please hit submit to email it to me at divorcenme48@gmail.com before the initial session. Any questions, be sure to contact me at 1-847-347-1675.

Thank You

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