Client Intake Form

Gender

What is your preferred method of communication? Please select from the following options: Email or phone?

Phone

How did you learn about our program?

if other, please specify

When would you like to begin the program?

How frequently would you like to have coaching sessions? (Once a week or Fortnight)

Can you commit to actively participating in the coaching process and completing any agreed-upon tasks?

Coaching You are Interested In:

Holistic Wellbeing (includes Life Coaching, Dietetic and Yoga)

Life Coaching

Dietetic

Yoga

Confidentiality and Boundaries:

We value client privacy and maintain strict confidentiality. Personal and sensitive information shared during sessions is kept confidential. We respect professional boundaries and uphold ethical standards. Clear boundaries ensure a safe and respectful environment. By signing this form, you acknowledge and agree to maintain session confidentiality and respect boundaries.

Cancellation Policy:

If you need to reschedule or cancel a session, please provide at least 48 hours notice; otherwise, the session fee may still apply.

I agree to the Privacy Policy

I would like to receive direct marketing from JEEVI Australia about marketing communications about services, offers, promotions and events

I have read and understood the Privacy Collection Notice.

Thank you for filling out the Client Intake Form. Our team at JEEVI Mental Health and Holistic Wellbeing Services will review your information and connect you with one of our experts who will reach out to you shortly. Our expert will assess your needs and provide you with options that suit your preferences, to help you achieve your mental health and holistic wellbeing goals.

Client Intake Form

Individual’s Details:

Salutations

Full Name *

Address *

Suburb *

State *

Country *

Age *

Email Address *

Mobile Number

Occupation *