Client Intake Form

Individual’s Details:


Full Name *

Address *

Suburb *

State *

Country *

Age *

Email Address *

Mobile Number

Occupation *


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

Confidentiality and 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.

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.