White Mountain Coaching Referral Form

Allow up to 24-48 hours to respond

Today's Date

Month

Day

Year

Is coaching services urgent:

Is this a new referral for adult or child:

Client's first name:

Client's last name:

Client's date of birth

Month

Day

Year

Client's email:

Client's address:

Client's phone number:

OK to leave messages for Client:

List other Coaching needs, if not listed:

Name of person whom is filling this form out, if not the client. If Client, put Client's name here again:

Address of person filling this form, if Client, skip:

Phone Number of person filing this form, if Client, skip:

OK to leave messages with person filling this form, if not the Client:

Parent's or Guardian's full name, if Client is above 18 years or older, skip:

Address of person filling this form, if Client, skip

Care Taker / Foster Care Provider of Client, if any, full name, if none skip:

Address for Care Taker / Foster Care Provider of Client, if any, if none, skip:

Phone number of Care Taker / Foster Care Provider, if any, if none, skip:

OK to leave messages with Care Taker / Foster Care Provider, if any, if none, skip:

Does the Client have Tribal affiliation, name of Tribe, and member number:

Name of person from School, if involved, if none, skip:

Name of school Client goes too, if involved, if none, skip:

Address of school Client goes to, if none, skip:

Phone number to reach school member or staff, if none skip:

Email address, for school member or staff, if none, skip:

OK to leave messages with school member or staff, if none, skip:

Other people involved with Client full name, if none, skip:

Phone number of other involved person, if none, skip:

OK to leave messages with other involved person, if none, skip:

Is the Client pregnant? Do you have any concerns for services, if pregnant:

Is the Client a Veteran or in active services:

Are you/Client having thoughts of hurting your self:

Are you/Client having thoughts of hurting others:

Doe the Client need special assistance to receive behavior coaching services? No ___ Yes ___, List what assistance is needed, explain if needed:

*** Check this box that you understand that this referral is for Behavior and Life Coaching Only and not therapy or counseling services related services. White Mountain Coaching does not provide services outside the scope of behavior coaching services.

This is a checkbox, if you understand no therapy or counseling is provided.