ERM Study Personal Profile

Section 1: Contact Information

ID Pseudonym*

Today's Date

Daytime Phone

(Please give best phone #(s) to contact you.)

Cell Phone

Landline Phone

Email address*

Section 2: Vital Statistics

Age

What is your occupation?

Number of children

If you have children, please list their names and ages:

Have you been in thearapy or counseling in the past?

Yes
No

Are you currently in therapy or counseling?

Yes
No

If yes, since what date and how often?

Have you ever been treated or hospitalized for a mental or emotional condition?

Yes
No
Not Sure

Are you taking any medications for mood stabilization or other mental or emotional health reasons?

Yes
No

If yes, please list name and dosage of each:

Have you ever been diagnosed with depression?

Yes
No

Do you now have, or have you had in the past year, thoughts of harming yourself or that you’d be better off dead?

Are you prone to bouts of anger?

How would you describe your state of mind over the past 3 months?

Overall good
Overall not good

If not good, please describe below:

Do you tend to have a pessimistic outlook or depressive personality?

Yes
No
Not sure
Others might say so

Do you have any physical health conditions that could make a day-long coaching session difficult for you?

Yes
No
Possibly

If yes or possibly, please describe below:

On a scale of 1 to 10, please rate the likelihood you feel the coaching will bring you your desired results. Please elaborate.

I understand that giving feedback on the survey forms provided or by email is important to the coaching process and I agree to fill out the various feedback questionnaires as requested.*

I agree
I disagree