4109 North 18th st
phoenix, arizona  85016
602.212.1000

  Background Information Form for First Step Life Coaching  
  Complete Form and Click Submit button at bottom when finished.  
Full Name

Age 

Address Date of Birth 
City   State 

Zip

Phone

Alternate Phone

E-Mail

Occupation

Relationship Status

Education

Primary Issues Prior Counseling


How did you hear about Dr. Bidot and First Step?
 
    Please describe the reason for your contact/ visit:
 
    What would you like to accomplish with First Step counseling services?
 
    List any major health problems for which you currently receive treatment:
 
    Ever received counseling or psychological/psychiatric help?
If Yes, please explain where and when:
 
    Please list all family members you live with:  Name, Age, Relationship, Occupation
 
    Please describe the reason for your contact/ visit:
 
    Do you consume alcoholic beverages? If so, in what form, how often, and how much.
 
    If you smoke, what form (cigarette, cigar, pipe) and how much
 
Are you a member of any church or religious order? If so, which?
    Do you believe in a God or a Deity?
 
    Have you ever practiced Meditation? Where?
 
    Please add any additional information you feel may be useful to a counselor.