iClient iNtake

iCenter™ Client Intake Form

Thank you for choosing iAuthentics™. Please complete this form as best you can. When you click Send My Intake Form, your email app will open with your answers ready to send directly to Jacqueline.

1. Contact Details

Full Name *

Email Address *

Phone Number (optional)

Preferred Pronouns

City / Time Zone

2. Support & Focus

What brings you to iCenter™ coaching at this time?

If our work together is supportive and effective, what would feel different in your life?

3. Well-Being & Readiness

Are you currently receiving any medical, psychological, or therapeutic care?

Is there anything about your mental or emotional well-being you would like me to be aware of for safety and support?

4. Goals & Intentions

What are 2–3 intentions or goals you would like to explore in coaching?

5. Consent & Agreement

Coaching with iAuthentics™ / iCenter™ is educational and supportive. It is not counseling, psychotherapy, or medical care, and no diagnosis or treatment is provided. You remain responsible for your choices, actions, and well-being.

I have read and agree to participate in iCenter™ coaching within this scope.

Anything else you would like me to know before we begin?

When you click "Send My Intake Form", your email app will open with your answers. Please tap send to complete your intake.