Please complete THE NEW CLIENT INFORMATION FORM: Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Best Email * Best Phone Number * (###) ### #### Date of Birth Occupation Religious/Spiritual Beliefs Marital Status Does your spouse/partner/significant other support you in seeking coaching? Yes No Not Sure N/A List the names, ages and relationship to you of each member of your household: Have you ever worked with a coach before? If so, please say what worked and what didn't work about your previous coaching experience: MEDICAL HISTORY Are you currently recieving treatment for a physical or psychological issue or disorder or have you been in the past year? Yes No If yes, please describe: Are you currently in therapy? (If you are currently in therapy please notify your therapist that you will be working with a coach) Yes No Please list any prescrpiton medicatins you are currently taking: Do you drink alcohol? If so, how much and how often: Do you use any controlled substances? If so, what, how much and how often: Are you currently experiencing any physical, mental, or emotional problems that you are not dealing with appropriately? If yes, please describe: COACHING GOALS What had you decide to hire a coach at this time? What are your expectations of coaching? What are the results you are committed to achieving? How would you descibe yourself? How do you want to be able to describe yourself by the end of our working together? What would you say is the biggest obstacle to you having the life you want? COACHING AGREEMENT: I would like to being the following Wisdoming 1:1 program: 3 Months Pre-Paid = $3000 (12 sessions) 6 Months Pre-Paid = $6000 (24 sessions) 9 Months Pre-Paid = $9000 (36 sessions) COACHING FEES: Pre-paid fees are due in full prior to the first scheduled session. Fees for individual coaching sessions are due at the time of each session. Fees may be paid via check, cash, credit or debit card, Venmo or Paypal. Pre-paid sessions must be used within 2 weeks of the end of the stated time frame. Any exceptions to this policy are at the discretion of the coach. SCHEDULING & CANCELATION POLICY: It is our experience that weekly coaching sessions produce the best outcomes, and scheduling your sessions at the same time on the same day each week is optimal. If you are on a pre-paid plan we will schedule as many of your appointments as possible in advance. We understand that it is not always possible to schedule on the same day and time. We will do our best to accommodate your needs. If you have an emergency and need to reschedule an appointment, please contact us as soon as you are aware that you will not be able to keep your appointment. Note: If you miss an appointment and do not call in advance, that session will be forfeited for pre-paid clients and billed at the full fee for per session clients. Repeatedly rescheduling appointments may result in the termination of our coaching relationship. COACHING RELATIONSHIP EXPECTATIONS: What you can expect from me: I promise to..... • Keep you focused on the results you are committed to. • Hold you accountable for what you say you want and what you say you will do. • Stand for your greatness and know who you really are, especially when you don't. • Know that you have all of the inner resources to respond to any situation. • Give you the dignity of your process. • Assist you in establishing your own solutions & strategies. • Challenge you to live an aware, conscious and authetic life. What I expect from you: I expect you to... • Be on time and prepared for your coaching sessions. • Be open and honest. • Be willing to examine, challenge and let go of your limiting beliefs. • Be accountable for your life/decisions/actions. • Be responsible for the results you are and are not producing. CLIENT AGREEMENTS: 1. As a client, I understand and agree that I am fully responsible for my physcial, mental and emotional well-being during my coaching calls, including my choices and decisions. I am aware that I can choose to discontinue coaching at any time. 2. I understand that "coaching" is a Professional-Client relationship I have with my coach that is designed to facilitate the creation/development of personal, professional or business goals and to develop and carry out a strategy/plan for achieving thos goals. 3. I understand that coahcing is a comprehensive process that may involve all areas of my life, including: work, finances, health, relationships, education and recreation. I acknowlege that deciding how to handle these issues, incorporate coaching into those areas, and implement my choices is exclusively my responsiblity. 4. I understand that coaching does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Associate. I understand that coaching is not a subsitute for counseling, psychotherapy, psychoanalysis, mental health care or substantce abuse treatment and I will not use it in place of any form of diagnosis, treatment or therapy. 5. I promise that if I am currently in therapy or otherwise under the care of a mental health professional, that I have consulted with the mental health care provider regarding the advisability of working with a coach and that this person is aware of my decision to proceed with the coaching relationship. 6. I understand the information will be held as confidential unless I state otherwise, in writing, except as required by law. 7. I understand that certain topics may be anonymously and hypothetically shared with other coaching professionals for training or consultation purposes. 8. I understand that coaching is not to be used as a subsitute for professional advice by legal, medical, financial, business, spiritual or other qualified professionals. I will seek independent professional guidance for legal, medical, fiancial, business, spiritual or other matters. I understand that all decisions in these areas are exclusively mine and I acknowlege that my decisions and my actions regarding them are my sole responsibility. SIGNATURE I have read and understand this questionnaire and the policies and agreements listed herein. To the best of my knowlege the information I have provided is complete and accurate. Please sign & date below: First Name Last Name Today's Date: MM DD YYYY We recieved your form & we are excited about serving you & your needs through coaching. Thanks so much.
