Personal Intake Form

Thank you for taking part in the OutoftheBurn pilot. These three coaching sessions are a space to explore what has been difficult, patterns that may be getting in the way, and what moving forward more sustainably could look like for you.

The sessions may include reflective questions and simple exercises informed by Acceptance and Commitment Training (ACT). This is coaching, not psychotherapy, medical treatment or crisis support.

You don’t need to tell your whole story here. A few sentences are enough, and please only share what you feel comfortable sharing.

Privacy

Your privacy matters. Information you share through this form or during our sessions will be treated as confidential and used for the purpose of providing these coaching sessions.

Your name, identity and information that could reasonably identify you will not be shared or published.

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What brings you to these sessions?

What feels most difficult for you at the moment?

When things become stressful or overwhelming, what do you tend to do?

useful, before tend

If these three sessions were useful, what would you hope to understand or do differently by the end?

Are you currently receiving support from a doctor, psychologist, therapist, psychiatrist, occupational doctor or another coach?

• Yes
• No
• Prefer not to say

Are you currently experiencing a mental health crisis, thoughts of harming yourself, or difficulty keeping yourself safe?

• Yes
• No

Is there anything else you would like me to know before we meet?

Name *

First

Last

Email *

Agreement – Please confirm the following before submitting:

• I understand that these sessions are part of an OutoftheBurn coaching pilot and are not psychotherapy, medical treatment or crisis support.
• I understand that I choose what I discuss and can stop participating at any time.
• I understand that if my needs appear to fall outside the scope of coaching, I may be encouraged to seek support from an appropriately qualified professional.

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