Individual Counselling & Coaching

Client Intake & Assessment

A confidential, evidence-based intake to help Dr. Nicole understand your unique situation and create a personalised, root-cause-based Lifestyle Prescription® for you.

Welcome — What to Expect

Using evidence-based Health Coaching Habit Change Techniques & Protocols, Dr. Nicole helps you:

Through a few targeted questions, you'll discover your 6 Root-Causes (the WHY and HOW) of your challenges, exactly which stress triggers, emotions, beliefs and lifestyle habits are affecting your symptoms, and where you are in the 9 phases of the self-healing process. Persons see results during their first session.

Radical transformation is possible. Imagine increments of change daily over 90 days — how much better life will be.

Session Fees First session (assessment): $100.00 / Fls 180.00 per hour. If over one hour: additional $50 / Fls 90.00 per half hour.

Scheduling: Please view Dr. Nicole's schedule and select a day and time that works for you this week.

Health Score: Please also complete your free Health Score assessment — we'll review the results together to identify nutrients that may support your health optimisation.
Please complete this form individually and honestly. All responses are strictly confidential and will only be seen by Dr. Nicole E. Francis Cotton. Once you have completed and submitted this form, please make your $100 deposit to confirm your appointment, then email Dr. Nicole if you have questions.
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Personal Information

Basic details to get started

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Presenting Concerns

What brings you here today?

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Depression Risk Indicators

Clinical screening — select any that currently apply to you

🔒 This information is strictly confidential and helps Dr. Nicole tailor her approach to your specific needs.
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Symptoms of Stress

Select all symptoms you are currently experiencing

A little stress is healthy — it keeps us alert and productive. However, too much stress can produce serious physical, emotional, and behavioural symptoms. Please select all that currently apply to you.

Physical

Emotional

Behavioural

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PHQ-4 — Anxiety & Depression Screen

4-item validated clinical screening (last 2 weeks)

Over the last two weeks, how often have you been bothered by the following?

Question
Not at all
(0) Several days
(1) More than half
(2) Nearly every day
(3)
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Feeling down, depressed, or hopeless
4. Little interest or pleasure in doing things

PHQ-4 © Kroenke K, Spitzer RL, Williams JB, Löwe B. Psychosomatics. 2009;50(6):613-21.

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PHQ-9 — Depression Assessment

9-item validated clinical screening (last 2 weeks)

Over the last two weeks, how often have you been bothered by any of the following?

Question
Not at all
(0) Several days
(1) More than half
(2) Nearly every day
(3)
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure, or have let yourself or your family down
7. Trouble concentrating on things, such as reading or watching television
8. Moving or speaking so slowly that others could have noticed — or being so fidgety or restless you've been moving more than usual
9. Thoughts that you would be better off dead, or of hurting yourself in some way

PHQ-9 © 1999 Pfizer Inc. All rights reserved. PRIME-MD is a trademark of Pfizer Inc.

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PHQ-15 — Physical Symptoms

During the past 4 weeks, how much have you been bothered by each of the following?

Symptom
Not bothered
(0) Bothered a little
(1) Bothered a lot
(2)
a. Stomach pain
b. Back pain
c. Pain in your arms, legs, or joints (knees, hips, etc.)
d. Menstrual cramps or other problems with your periods (Women only)
e. Headaches
f. Chest pain
g. Dizziness
h. Fainting spells
i. Feeling your heart pound or race
j. Shortness of breath
k. Pain or problems during sexual intercourse
l. Constipation, loose bowels, or diarrhoea
m. Nausea, gas, or indigestion
n. Feeling tired or having low energy
o. Trouble sleeping

PHQ-15 developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.

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Personal Anger Assessment

Select the statement that most closely describes how you would respond in each scenario

Read each scenario and choose the response that best matches you — even if it's not a perfect fit. Be as honest as possible.

Scenario 1 — Arguments with loved ones:

Scenario 2 — Losing your temper:

Scenario 3 — Getting over anger:

Scenario 4 — Managing anger strategies:

Scenario 5 — Acting out in anger:

Scenario 6 — Retaliatory anger:

Scenario 7 — Anger at work:

Adapted from the Personal Anger Assessment by Dr. Gary Chapman — Anger: Taming a Powerful Emotion. Visit 5lovelanguages.com.

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Safety Assessment

Your safety is our first priority — all responses are strictly confidential

🔒 This section is strictly confidential. These questions are standard clinical practice and help Dr. Nicole provide the most appropriate and safe level of care for you.

Rate each of the following on a scale of 1–5:

Current level of depression:
1 — Not depressed5 — Very depressed
Current sense of hopelessness:
1 — Optimistic5 — Hopeless
Current level of social support:
1 — High support5 — No support

Suicide Assessment adapted from TherapistAid.com © 2012. Used for clinical intake screening purposes.

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Personal Peace Assessment

Rate your current peace or satisfaction in each life area (0–100%)

Enter a number from 0 (no peace) to 100 (complete peace) for each area.

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Pinpointing Your Pain

List your key pain points — the things causing you the most emotional distress

CGU Childhood / Growing Up FM Family Matters F Friends RR Romantic Relationships WCS Work / College / Social Y Yourself
Pain Point TitleRank (1–10)CategoryBrief note (optional)
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Email Communication Consent

For communicating with Dr. Nicole E. Francis Cotton

📋 Please read carefully before signing. This explains how email is used in your therapeutic relationship.

About communicating via email with Dr. N. Erna Mae Francis Cotton and Roy Cotton Jr.:

E-mail is not fully secure or confidential. Hackers and unauthorised users can attempt to access email through malicious software. There is no guarantee that security programmes will always be effective.

Sent and received e-mails are stored on Dr. Francis Cotton's computer until deleted. Any saved e-mails will be kept in a password-protected account that only Dr. Francis Cotton has access to. Authorities can also access e-mails under various legal circumstances.

Dr. N. Erna Mae Francis Cotton does not conduct therapy via e-mail. However, she may use e-mail to handle certain questions or issues that pertain to therapy and can be easily handled by that means. At her discretion, she may choose to refrain from e-mail for therapeutic reasons.

If you request that your billing statement be e-mailed to you, she will do so. A rule: billing and scheduling questions are appropriate for e-mail; clinical/therapeutic content is addressed in sessions.

Your typed name serves as your electronic signature confirming you have read and understood the above disclosure.

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Final Confirmation

Your responses will be sent securely to Dr. Nicole E. Francis Cotton. She will be in touch within 48 hours to confirm your appointment. Please remember to make your $100 / Fls 180 deposit to confirm your session.

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Thank you — your assessment has been received.
Dr. Nicole will be in touch within 48 hours.
Remember to complete your Health Score and make your deposit to confirm your session.