Embedded Files
Client Intake
Last updated: 24 February 2026
Name: _______________________________ Address: ________________________
Phone Home: ________________________ Phone Work: _____________________
Phone Cell: __________________________ Email: ___________________________
What days & times are best to contact: ___________________________________
Okay to leave a phone message? ☐ Yes ☐ No
Text Message? ☐ Yes ☐ No
Email? ☐ Yes ☐ No
Age
Date of Birth
Marital Status
Gender/Pronouns
Ethnicity/Race
Occupation: __________________________ Employer: _______________________
Emergency Contact: __________________ Relationship: ____________________
Phone Cell: ___________________________ Phone Other: ____________________
Referral Source: ________________________________________________________
Confidentiality: I adhere to a strict standard of confidentiality. All the information between you and anyone employed by ThreeOwl Awareness (including myself, an intake counsellor or other staff members) will not be shared or disclosed to anyone without permission from you.
Limits of Confidentiality: Coaches keep information related to coaching services confidential with the following noted exceptions: (a) files are demanded under a subpoena for the court; (b) the client reports current, active suicidal/homicidal intent; (c) the client &/or counsellor are at risk of harm; (d) the client reports current (not historical) suspected abuse or neglect of a vulnerable person, in which case, the relevant information is disclosed to the appropriate authority in the jurisdiction in which the client resides. ThreeOwl Awareness will discuss this with you before disclosing.
Ethics: I adhere to the ICF Code of Ethics (International Coaching Federation). More information can be found on their website.
By signing below, I indicate that I understand the above.
Signature: __________________________________ Date: _________________________________
By typing your name in the “Signature” space, you agree to an eSignature.
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