Contact Brook

Please be sure that you have talked to me, either in person or on the telephone, prior to completing this form. This intake and information form is provided as a convenient and time effective means of helping me get to know you better, and will provide me with important information that will make our first meeting more effective and efficient. It will also save you time and money. Please be sure to complete the entire form and email back to me as soon as possible so that I have this information for your first session. If you have any questions, please feel free to contact me at 281-703-7400.

* First Name
* Last Name
* Date
Address for mailing
City
State
Zip Code
Location
Interesting work
Making a contribution
Flexible Hours
Opportunities for Advancement
Leadership Role
Work-life balance
Technical usage
Prestigious organization
Structure and organization
Outdoors/nature work
Service to others
How did you hear about Lone Star Career Solutions?

* Email
* Cell #
* Is it ok for us to leave a message for you at this number? Yes No
* Is it ok for us to text you at this number? Yes No
Would you be interested in Skyping some or all of your sessions for a per hour discounted price? Yes  No
If so, what is your Skype name:
Emergency Contact
Name
Phone
Age
What is your mother's occupation?
What is your father's occupation?
List your sibling's occupations:
Are you currently employed? Yes No
Your Current Job
Please give a brief job description
Years in Your Current Job
Your Current Company
Years in your Current Company
Are you having any difficulties in your current job? If so, please briefly describe those difficulties
What do you like least about your current/last job?
* What are your career goals? (Even if you are very uncertain, just fill in any thoughts that you might have.)
Are there other current issues (i.e. family or health) that may impact your current interest in your career or in obtaining career counseling?
On a 1-10 scale (1= least, 10 = greatest) rate how hard a worker you are (circle one)? 1 2 3 4 5
6 7 8 9 10
Please list your last few jobs, give the job title, company and years
Please describe your educational history (including the highest level of formal education you have attained and any specialized training that may be helpful to you)
What was your major?
What was your minor?
What GPA did you graduate with?
What are your income requirements for your next job, if appropriate?
What are the skill requirements for your next job?
As a child what did you want to be when you grew up?
If you could have any job, what would it be?
What do you consider to be some of your strengths?
What do you consider to be some of the areas you need improvement in?
Check the 3-5 values below that are most important to you regarding your career?
AchievementInnovation and Creativity
Helping othersEnvironment
MoneyPower
Status Recognition
Camaraderie/fellowship Free time / leisure
Self - DirectionStability
Job SecurityVariety
AuthorityFast Pace
CompetitionChallenge
Adventure Autonomy
What volunteer experiences have you had or would you like to do in the future?
Please list any hobbies and ways you like to spend your free time?
Do you enjoy reading? Yes No
If yes, what category/kind of books do you like to read?
Spouse or significant other
Name
Age
Occupation
Ages of children if applicable
Are there any health or family issues that may impact your career? If so, please briefly describe:
Signature: