Client Intake Form/Consent/Release of Liability

Client Name*

First NameLast Name

Email*

example@example.com

Mobile Phone Number*

Please enter a valid phone number.

Home Phone Number

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How did you learn about Nancy Rae Coaching?

What issue(s) are you hoping to address through coaching?*

How committed are you to making shifts in your life to address these issues?*

Extremely committedSomewhat committedNot very committed

Clients often find great success when a coach can point out patterns that they see in a client's thoughts, words, and actions. You may not notice these yourself, and they may be holding you back from experiencing success in various areas of your life. Please describe how open you are to hearing a different perspective than you may be aware of about your thoughts, words, and actions and how they may be thwarting your experience of contentment in your life. *

Check any that apply*

I consider myself to be religious.I consider myself to be spiritual.I consider myself to be secular (non-religious, non-spiritual).I prefer to see life phenomena through the lens of scientific explanation.I don't relate to any of the above and I don't really think about it.

If you seek guidance from a Higher Power, what name(s) do you prefer using? (ie., God, Spirit, Source, Universe, Holy Spirit, Jesus, the Divine, the One, Buddha, Jehovah, Lord, Spirit Guides, Jahveh, Allah, Inner Self, Nature, etc.) List any that apply or N/A.*

If you have any questions regarding coaching with Nancy Rae Coaching, please list them here.

Consent and Release of Liability

The Session Process

Nancy's role is to facilitate shifts in your perception, thinking, behavior, and lifestyle that lead to positive changes in your personal development, relationships, career, spirituality, and health. Throughout the coaching relationship, she will engage in direct and personal conversations with you. She will help you be accountable for actions you would like to take that will lead to your growth and sustained achievement of your goals.

Scheduling

Please fill out the contact form on this website, email Nancy at nancy@nancyraecoaching.com, or call (805) 203-0558 to request an appointment. Nancy will get in touch with you within 24 hours to schedule your coaching session(s).

Coaching sessions are done over the phone. Nancy will initiate the video call at the time of the session.

Investment

This agreement is between Nancy Rae and the above named client.

The investment for coaching sessions is $110 per session. This includes a 50-minute one-on-one coaching session, with email/text support and resources as needed between weekly sessions.

Sessions may be purchased one at a time. Alternatively, you may choose to purchase a session bundle and additional appointments may be scheduled as needed. Bundle:

4 sessions - $400

There are no refunds on sessions. There are no refunds on courses or events after they have been delivered.

Payment Procedure

All sessions are paid in advance by PayPal, Venmo, check, or cash/money order. Your session can be conducted after this agreement is acknowledged and on file and your payment is received. Any changes to the procedure must be mutually agreed upon in writing.

Session Time and Call Procedure

Sessions are by appointment only and last 50 minutes. In between sessions, if you wish to briefly connect with Nancy with a challenge, a success, or an inquiry, she will make every attempt to respond within 24 hours with an email or text. For daily accountability texts, if desired by clients, she will read each text but may not respond daily.

Late, Missed, and Cancelled Sessions

Keeping appointments and staying on time is in everyone's best interest. You will want to make the most of your appointment time, and other clients also count on getting their appointments on time. If you need to cancel an appointment, please provide at least 24 hours' notice or you will be charged for the appointment, barring an emergency or unforeseen circumstances. If Nancy should need to reschedule, she will make every attempt to give you at least 24 hours' notice as well, barring an emergency or unforeseen circumstances.

Only under dire extenuating circumstances will unused portions of packages be refunded.

Communication

Nancy's most sincere intention is to have a professional relationship with every client that is fully open, honest, real, and trusting. She is very aware that communication styles, word choice, and vernaculars differ from person to person and wants to honor that with each client. Should you ever feel that you need clarification or a deeper understanding of something discussed in your session, please bring it to her attention promptly.

Confidentiality

All information about the coach/client relationship will remain strictly confidential except in very rare circumstances where required by law. Exceptions to confidentiality relate to circumstances such as intent to seriously harm someone, child abuse, thoughts of suicide, etc. Otherwise, all other information is kept confidential.

Disclaimer

The Client understands that Nancy Rae's role as a Life and Health Coach is not to provide counseling, therapy, health care, medical or nutrition therapy services; or to treat or cure any disease, condition or other physical or mental ailment of the human body. Rather, she is a mentor and guide who has been trained in holistic health and life coaching to help clients reach their own goals by facilitating shifts in their perception, thinking, behavior, and lifestyle that lead to positive, sustainable changes in their personal development, relationships, career, spirituality, and health. The client understands that she is not acting in the capacity of a psychologist, psychiatrist, doctor, licensed dietician-nutritionist, or other licensed or registered professional, and that any advice given by her is not meant to take the place of advice by these professionals. If the client is under the care of a health care professional or currently uses prescription medications, the client should discuss any dietary changes or potential dietary supplement use with his or her doctor, and should not discontinue any prescription medications without first consulting his or her doctor.

Consent and Release of Liability

I, * , have read and fully understand the Session Consent and Agreement, and my signed submission is my agreement should I choose to purchase and receive one or more coaching sessions, now or in the future, from Nancy Rae of Nancy Rae Coaching.

I agree to take full responsibility for my self-care in the emotional, mental, physical, and spiritual areas of my life and to seek professional advice before making any health decisions, including using Nancy Rae Coaching. Further, I assume and agree to accept full and complete responsibility for applying what I may learn from my coaching sessions with myself or others.

Any stories or testimonials presented on this website or during a session, or in informal conversation, do not constitute a warranty, guarantee, or prediction regarding my outcomes using Nancy Rae Coaching for any particular issues.

Except in the case of gross negligence or malpractice, my representative(s) or I agree to fully release and hold harmless Nancy Rae/Nancy Rae Coaching from and against any and all claims or liability of whatsoever kind or nature arising out of, or in connection with, my session(s).

Please indicate your acceptance and agreement by signing in the space provided below.

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Date:

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