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If applicable, what is/are your current diagnoses?

If applicable, what side effects and/or symptoms are you currently experiencing?

This is not for diagnosis or treatment. This will act as a resource your upcoming appointment.

Date and duration of your upcoming appointment

Ex. August 19, 2022, 25 minutes with doctor

Type of appointment, testing, or procedure that you want support around?

Be as specific as possible here. Practitioner: Include their line of work/area expertise. Is this the first appointment? Or are you an existing patient/client? Testing: What type(s) of testing will you have? Ex. MRI, pulmonary function test, tilt table, etc. Procedure: What type of procedure is being performed? Is this your first time?, How long does the procedure take?

Will someone be attending this appointment with you?

If yes, who?

How are you feeling about this upcoming appointment, testing, or procedure?

Are there any boundaries that you desire around this upcoming appointment, testing, or procedure?

Do you have any physical/emotional/spiritual tools that currently support you?

If yes, what are they? If not, are you seeking anything in particular?

What is your hope for our session together?

Is there anything else that you would like me to know?

Jillian Parkhurst

Jillian Parkhurst

Appointment Prep Intake Form

Jillian Parkhurst

1:1 Coaching: Appointment Prep Session
Please complete the form below so that I can learn a little bit about you, your challenges, and your goals prior to our first session together. Be sure to submit this form at least 24 hours prior to our call. Thank you!

Jillian Parkhurst

Jillian Parkhurst

Appointment Prep Intake Form

Jillian Parkhurst

1:1 Coaching: Appointment Prep SessionPlease complete the form below so that I can learn a little bit about you, your challenges, and your goals prior to our first session together. Be sure to submit this form at least 24 hours prior to our call. Thank you!

1:1 Coaching: Appointment Prep Session
Please complete the form below so that I can learn a little bit about you, your challenges, and your goals prior to our first session together. Be sure to submit this form at least 24 hours prior to our call. Thank you!