Mental Coaching Intake Form

Phone (optional)

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When do you feel the most joy in your life?

When spending time with myself.

Surrounded by close friends and family.

Where's the party?

Depends on the day.

Are you working with any of the following: *

anxiety

depression

over/under eating

exhaustion

troubled sleeping patterns

low levels of energy and movement

other

none of the above

I understand and agree that I am fully responsible for my well-being during my coaching sessions, and subsequently, including my choices and decisions. I understand that coaching is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy. I understand that all comments and ideas offered by my Coach are solely for the purpose of aiding me in achieving my defined goals. I have the ability to give my informed consent, and hereby give such consent to my coach to assist me in achieving such goals. *

Yes I agree, & will seek additional help as necessary.

No, I don't agree.

RELEASE: Except as expressly provided in this Agreement, the Coach makes no guarantees, representations or warranties of any kind or nature, express or implied with respect to the coaching services negotiated, agreed upon and rendered. In no event shall the Coach be liable to the Client for any indirect, consequential or special damages. Notwithstanding any damages that the Client may incur, the Coach’s entire liability under this Agreement, and the Client’s exclusive remedy, shall be limited to the amount actually paid by the Client to the Coach under this Agreement for all coaching services rendered through and including the termination date. *

Yes! I am an adult and will respect my own body!

I wish to sue your pants off for no reason.