Intake Form

Date

Client Name

First

Last

Parent/Guardian Name (if applicable)

First

Last

Date of birth

Address

Phone Number

How did you hear about Shannon Sciametta’s services?

Have you previously worked with a health coach, therapist, or other wellness professional? If yes, please describe.

What are the main goals you hope to achieve through holistic coaching and/or therapy?

What changes would you like to see in yourself or your child/family?

Are there specific challenges you want support with (e.g., nutrition, stress management, behavioral support, emotional regulation, social skills, daily routines)?

Are there any practices or approaches you prefer or want to avoid?

Who are the key support people in your life (family, friends, therapists, educators)?

Are there any environmental factors that may affect progress (home, school, work, stressors)?

How do you or your child typically cope with stress or challenges?

Have any therapies, interventions, or programs been tried previously? Please describe what worked and what didn’t.

Are there any complementary or alternative approaches you have tried (e.g., dietary changes, supplements)?

What is the best way for Shannon to communicate with you (email, phone, telehealth platform)?

Are there specific times that work best for coaching or therapy sessions?

Are there any accommodations or support strategies that would help during sessions?

Please share anything else you think Shannon should know to provide the best support for you or your child:

Acknowledgement - Please sign

I understand that participation in holistic coaching and/or therapeutic services is voluntary. I understand that Shannon Sciametta is a Holistic Coach and Holistic Therapist and is not a medical provider. The services provided are for support, guidance, and skill-building and are not a substitute for medical or professional advice.

Date

Intake Form

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