Client Profile Form

Name

First Name

Last Name

Preferred Name

(What I should call you, if different than your first name)

Cell Phone Number

Please provide a number at which you can be easily reached. This will be used to get in touch with you in case: -- A spotty internet connection interrupts one of our video calls. -- I have an emergency or conflict that affects a scheduled session (I may send a text to reschedule).

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate

YYYY

About You:

Any websites or social media handles relevant to your goals for coaching:

Hobbies, and/or things you enjoy spending time doing:

Favorite books, movies, musicians, albums, shows, etc:

Do you have ADHD?

Yes or I’m not Sure: Please complete the “ADHD and You” Section No: Please skip “ADHD and You” and go on to “Work Life”

Yes

I'm not sure

ADHD and You

Have you been formally diagnosed with ADHD?

If yes, when were you diagnosed? (How long ago, if applicable)

Anything you’d like me to know about your ADHD diagnosis experience?

Work Life

Current Occupation / Job (if applicable)

Role/Title Employer/Company Profession/Industry

How long have you been in this role?

(if applicable)

Current Occupation / Job (if applicable)

Role/Title Employer/Company Profession/Industry

Please complete this form to tell me about yourself.
The purpose of this form is to provide some basic information on who you are prior to your first session. Only certain fields are required, and the rest are optional, so feel free to share as much as you are comfortable.

Client Profile Form

Julia Rice & Co | Coaching & Consulting