HOLLY HELLER

Liver & Hepatitis Counseling & Coaching Support

Confidential Questionnaire

   
e-mail address:______________________@___________________________

Name__________________________________________Age_______Birthdate_____________

Home Address_________________________________________________________________

            City/Zip_________________________________________________________________

Home Telephone___________________________Bus_______________Fax_______________

Educational Level_____________________ Occupation_______________________________

Business Firm__________________________________________________________________

Business Address_______________________________________________________________

Marital Status_________________________________ Years Married_____________________

Spouse/Significant Other Name_________________________________________ Age______

Home Address__________________________________________Phone_______________

Present Status/Symptoms________________________________________________________

Medications____________________________________________________________________

Psychiatric/Psychological Care? ______________________Medications?__________

Name of Doctors_________________________________________________________

COACH TERMS

Fees:                $________for _______sessions per month

Session Day:     Monday         Tuesday          Wednesday       Thursday         Friday

Session Time:   _________am     pm      PT    MT    CT    ET    other__________________

Duration:           approx. 30 – 45 minutes per session

Procedures:

·         Contact Holly Heller  hepcounselor@aol.com or (818) 996-5135

·         If you call and get my voice mail, please call back after one full minute

·         Please do not leave a message and wait for me to call you back.

I understand that Holly Heller is not a licensed therapist and that I am responsible for all my decisions, actions and feelings. 

Client Signature________________________________________________Date_________

Holly Heller, Hepatitis Counselor & Certified Coach
hepcounselor@aol.com         www.hepatitiscounselor.com
19528 Ventura Blvd. Ste 460 Tarzana, CA 91356

818-996-5135 or 818-203-2085 
FAX 818-996-4477