Intake Coaching Clients

Full Name(required)

Email(required)

Phone(required)

Mailing Address(required)

City State Zip(required)

Birth Date(required)

What do you most hope to accomplish from this coaching service? Be specific if you can.(required)

Which statements do you identify with? You can select more than one.(required)

I consider myself a dreamer or creative. I consider myself skilled at various sports or physical feats. I may do tasks/activities in my dreams before doing them in physical reality. I tend to work long hours and have been accused of being a workaholic or busy-body. I had a lot of energy as a child and found it difficult to sit still. I find it easier to think about and plan doing things than physically doing them. Sometimes after dreaming I feel like I have been working all night. I don't understand why it's so hard for some people to get things done. None.

What is your spiritual, religious or life philosophy?(required)

Have you experienced any significant life changes in the past year, if so what?

Do you have any concerns, medical issues, or is there anything you think I should be aware of before we begin working together?

Confirmation of agreement:

I agree that I am responsible for choosing my own goals and taking action toward those goals.(required)

I agree to communicate honestly and that if something doesn't "feel right", I will address it with my practitioner so that other options can be explored. I understand I can decline to discuss any issue, if I do not feel comfortable doing so.(required)

I agree to stay open toward feedback, questions and experimenting with new actions, behaviors or strategies to create the results I want.(required)

I agree that coaching fees are non-refundable, even if I choose to discontinue service mid-term.(required)

I understand that information shared will be held as confidential unless I request otherwise, in writing, except as required by law. Further, I agree it is my sole responsibility to determine what information is safe to share through internet, text or email providers.(required)

I promise that if I am in the care of a medical doctor or licensed mental health professional, that I have consulted with my healthcare provider regarding advisability of working with a coach and that this person is aware of my decision to proceed with the coaching relationship.(required)

I am of legal age and I am aware that this program is non-medical in nature and for any prescription, diagnoses or treatment I will consult my licensed healthcare practitioner. I understand that personal results may vary and that there are no expressed or implied guarantees or warranties of results. I understand that coaching requires follow-through and action on my part, and a desire to succeed, in order to create change or success. By typing my name in the box below, I acknowledge I have read the preceding statements and am in full agreement.(required)

Today's Date(required)

Intake Coaching Clients

Welcome

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Client Intake Form