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Positive   Break   Call us:205-621-9524

  Don't let your past
dictate who you are,
but let it be a lesson
that strengthens the
Person you will become.
   


 www.contact@positivebreak.com

                         Client  - Information:​

Contact Us
Name:
Date:
Address:
City:
State:
Date of Birth:
Zip:
Home Phone:
Work Phone:
Cell:
Marital Status:
Spouse/ Partner Name if any:
If we are unable to reach you, can we contact your spouse/ partner?
Their Contact Number:
Employer Name and Company Name:
Emergency Contact Information:
Current Physician Name:
Address Phone:
Referent - Who referred you?
Describe the Problem that brought you here:
Please check all the behaviors or symptoms that you consider problematic:
Distractibility:
Loneliness:
Arguing:
Impulsive:
Change in Appetite:
Boredom/ Fatigue:
Angry:
Low Esteem:
Thoughts of death:
Homicidal:
Guilt/ Shame:
Hyperactivity:
Anxiety:
Depression:
Sadness:
Hallucinations:
No Motivation:
Seasonal Mood Swings:
Paranoid:
Hopelessness:
Panic Attacks:
Hearing Voices:
Obsessive:
Crying spells:
Racing Thoughts:
Marriage Problems:
Social Anxiety:
Self-harm behaviors:
Fear away From:
Pornography:
Grief
Disturbing Memories:
Relationships:
Dug Use:
Alcohol:
Compulsive:
Parenting Issues:
Weight Loss:
Eating Issues:
Gambling:
Problems:
Faith Issues:
Divorce Problems:
Career Issues:
Teens out of Control:
Finances:
Abuse :
Emotional Issues:
Are your problems affecting any of the following:
Relationships:
Self Esteem:
Handling Everyday Tasks:
Legal Matters:
Housing:
Work/ School:
Hygiene:
Health:
Sexual Activity:
Finances:
Recreational Activities:
Internet Addiction:
If you are not serious, please don't fill out the intake form. Our coach is a professional and her time is very valuable. We support you in achieving your goals and living a fulfilling life
My aims to help you achieve clarity and confidence to work through issues that are holding you back so you can enjoy a harmonious life.

A - Coaching Relationship invites a safe, sacred space for exploring life. Experiences and making a purposeful difference in the areas of your life, you hold important the key.

Identify your values, strength and goals. Create an efficient time management system 
Thrive in time of transition manage stress.  
Look within for the answers, the noise outside is just that!
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