Life Consulting - Courtney Felke

LIFE CONSULTING LIABILITY RELEASE FOR COURTNEY FELKE:
It is mandatory for you to read this form and print your name at the bottom as an electronic signature that you do agree with everything listed. If you cannot agree to these terms I will not be able to move forward with Life Consulting.
I acknowledge that Courtney Felke has voluntarily agreed to participate in discovering the belief systems that govern my life and through various methods created by her aspires to help me change those beliefs to ones that I desire to have.*

Yes
I understand that this session is not a professional counseling meeting and that Courtney is not a licensed counselor, psychologist, psychiatrist, psychotherapist, or medical doctor.*

Yes
I further state that I have voluntarily sought assistance of my own initiative and that I am under no obligation to accept or reject any of the advice, opinions, or help that I might receive from Courtney Felke*

Yes
I understand that during these Life Consulting sessions I will be confronting my inner feelings and emotions, which could cause emotional pain and distress.*

Yes
I understand that at any time Courtney, or I, may refuse to engage in further communications and be free to terminate my sessions with no further obligation.*

Yes
I understand that if I receive Life Consulting from Courtney Felke, she is committed to respect the disclosed information, but is not held to complete confidentiality.*

Yes
I understand that in the event that she is led to believe that I may harm myself and/or others she will take the appropriate steps to detour this from happening.*

Yes
I agree to hold Courtney Felke free from any and all liability for loss, or damage of any kind, be it mental, emotional, relational, or financial, that may arise as a result of the assistance that I have received from her.*

Yes
By typing my name I am electronically giving my signature to agree with the following: I have read this Liability Release and understand and agree with everything in it and have executed it as my free and voluntary act.*

Yes
By typing my name I am electronically giving my signature to agree with the following: I have read this Liability Release and understand and agree with everything in it and have executed it as my free and voluntary act. -Spouse/Significant Other attending
Name*

First NameLast Name
Date*

MonthDayYear
Date
NEW CLIENT INFORMATION FOR COURTNEY FELKE:
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Gender*

MaleFemale
Age*

MonthDayYear
Date
What time zone are you in?*
How frequently would you like to meet?*

WeeklyTwice a MonthOnce a MonthOccasionally
Have you had sessions in any of the following fields before:*

Life CoachingCounselingTherapyPsychiatryInner HealingSozo
If you have, how regularly did they occur?*
Please tell me about your experience. Was it helpful? If so, what breakthroughs did you receive? Was it a positive or negative experience and why?*
Have you ever been diagnosed with a mental illness?*

YesNo
If yes, please give a brief overview of your diagnosis. *
Please list any medication you have been on in that past or are currently on.*
Do you have a history of alcohol or drug abuse? If yes, please explain.*
Please check any of the major emotions you are wanting to overcome:*

FearAnxietyAngerRageSelf-HatredLonelinessDepressionSadnessHopelessnessRejectionUnforgivenessDoubtAbandonmentShameGuiltCondemnationEmotional PainOther
Please briefly elaborate on what you are wanting to overcome:*
Please check any of the major life experiences that you are wanting to discuss:*

MarriageRomantic RelationshipsFriendship(s)JobFuture AspirationsSpiritual BeliefsInspirationChildhood TraumaCurrent TraumaAbuseDeath of a Loved OneRapeMolestationAddictionSexual ProblemsOther
Please briefly elaborate on the above check boxes.*
Who referred you to me?*
IMPORTANT INFORMATION TO KNOW ABOUT LIFE CONSULTING:
Please read the following and sign below:

It is the goal of Life Consulting to establish a personal identity (thoughts, feelings and emotions towards oneself) that is foundationally based in love and acceptance. The goal of Life Consulting is not to fix you but rather empower you through love and support in order for you to make a change. Life Consulting, simply said, is coming alongside an individual and walking hand in hand together in the journey of discovering the greatness of oneself.

I believe that each and every human being has been created as a powerful creator, no matter their gender, social, or economic status. I believe that every individual’s experience of this world is created from their own personal perspective developed through years of thought and belief. I believe life circumstances are subject to change as the beliefs within an individual change. Thus, each and every individual has the power to govern their lives. I believe that shame, guilt, and condemnation towards self will only yield destructive actions and reactions within life.

My commitment to you during our scheduled appointments is to devote myself completely to listening to you; understanding you, and doing all I can to help you discover what it is that you believe about yourself and your life. It is my highest goal to create an environment in which you feel safe, seen, known, heard, and loved, thus feeling comfortable enough to be honest and transparent about all of your thoughts and feelings.
WHAT YOU CAN EXPECT:

1. I will ask you a lot of questions. The goal of asking questions is for the purpose of knowing you and you knowing yourself. There is no question with regards to your life that is off limits unless specified by you the client. This is an environment where you are urged to be very open and transparent.

2. There will be homework assignments. After most sessions homework assignments will be given to you. These assignments are meant to help you accelerate your transformation process and give you practical ways to change and grow outside of our meeting times. Your homework being complete is not mandatory, however it will save you time and money and will help you to get so much more out of your sessions.

WHAT I EXPECT FROM YOU:

1. You will need to have a desire for change. If desire for change is not the number one desire in your heart at the moment of signing this, our time together will not be well spent. Without change as your greatest desire you will not face the many fears that govern how you think and what you believe.

2. You will need to have a commitment to honesty and transparency in regards to your experiences, thoughts, feelings, and emotions. I want you to feel safe enough to share anything, even the stuff you have never said out loud. I have seen that the people who are the most honest get the fastest breakthrough because I cannot help you get breakthrough if I do not see the whole picture.

CANCELLATION/MISSED APPOINTMENT POLICY:

Any cancellations or missed appointments that are not done 24 hours prior to the scheduled appointment will be billed in full, unless it is an emergency or illness that you let me know about as soon as possible. I will wait 10 minutes for a client to show up for an appointment, if I don't hear from you in that time the appointment will be considered a "no show" and require full payment. This is a strict policy which you are agreeing to upon completing the scheduling of this appointment.

SKYPE APPOINTMENTS:

I ask that you treat the Skype appointments just as you would an in-office appointment. If you have children, please arrange for someone to watch them during your session. If there are children present, I will need to cancel the appointment and it will be billed as a missed appointment.

FEES:

I accept cash, CashApp, Venmo or PayPal as a form of payment. If you are paying with CashApp, Venmo, or PayPal your payment is due prior to the meeting. Skype appointments always require payment online prior to the meeting. Please prepare your payment ahead of time so that you don’t use the session time for payment.

AVAILABILITY AFTER HOURS:

Under normal circumstances I am available through e-mail only. If you ever find yourself in a life-threatening emergency, call 911 immediately!

By complething this form, I acknowledge that I have read and understand the conditions and expectations of my Life Consulting session with Courtney Felke. Any further questions or inquiries that I have about Life Consulting I acknowledge that I have asked before the signing of this document.
Print Name*
Date:*

MonthDayYear
Date
I have been in email communication with Courtney and she has confirmed me as one of her clients.*

Yes
I have read the above information about Life Consulting and agree to the stated terms.*

Yes
I have read and agree to the cancelation policy above*

Yes
What do you want to get out of meeting with Courtney?*
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