Assessment and Discovery Form

Thank you for taking the first step. This form will help us understand your needs so we can make the most of our conversation together.

Client Information

Full Name:

DOB:

Address:

Email:

Phone Number:

Preferred Method of Contact:

Does client have a legal guardian? Y/N

If yes, name of guardian and contact info:

Caregiver Information

Full name:

Relationship to client:

Address:

Email:

Phone Number:

Emergency Contact Information

Full name:

Relationship to client:

Address:

Email:

Phone Number:

Disability and Health Information

Primary Diagnosis: (Check all that apply)

ABI
SCI
Stroke
Other neurological

Secondary Dx (MH)

Other:

Insurance/Benefit Information

Insurance Type	Yes	No
VA- Health Care
Medicare
Medicaid
SSI/SSDI, Private Health Insurance
Worker’s Compensation

1. Life Satisfaction Overview

On a scale of 1–10 (1 = very dissatisfied, 10 = extremely satisfied), how satisfied are you with the following areas of your life?

Life Area	Rating (1–10)	Comments/Notes
Social & Community Life
Housing & Neighborhood
Education & Employment
Lifestyle & Daily Habits
Access to Healthcare

2. Current Challenges

What are the main challenges or obstacles you’re currently facing? (Check all that apply or add your own.)

3. Goals & Aspirations

What would you like to achieve through NCC support? (Short-term and long-term goals)

Short-term goals:

Long-term goals:

Notes:

4. Motivation & Readiness

How motivated are you to make changes in your life? (1 = not motivated at all, 10 = fully committed)

What’s driving you to seek support and coaching now?

5. Support & Resources

Who or what currently supports you in life?

What has helped you grow in the past?

6. Expectations

What are you hoping to gain from supports with NCC?

What are your goals?

Assessment and Discovery Form

Client Information

Caregiver Information

Emergency Contact Information

Disability and Health Information

Insurance/Benefit Information

1. Life Satisfaction Overview

2. Current Challenges

The Client

Family Members

3. Goals & Aspirations

4. Motivation & Readiness

5. Support & Resources

6. Expectations