Client Intake Form

Client Intake Form and Agreement

Transformative coaching is a thought-provoking and creative relationship between the coach and the client. It aims to inspire the client and facilitate the creation of personal, professional or business visions.
Agreed Coaching Package*

1 on 1 Coaching - ($150 per session)Professional Mentoring ($150 per session)ASHC Strategy Sessions x 3 ($450)Other
Client Name*

First NameLast Name
Gender*

FemaleMaleOther
Date of Birth*

DayMonthYear
Date
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Relationship to Emergency Contact*
Medical Background
Have you ever been diagnosed with a medical condition or mental illness?*

YesNo
If you answered Yes above please provide details.
Are you currently taking any medication?*

YesNo
If you answered Yes above please provide details.
Are you currently working with any other medical professionals? Please specify.*
Knowing You Better
Have you ever worked with a counsellor or coach before? If Yes, what was your experience?*
Choose 3 words to describe your personality:*
3 areas that are a priority for you right now:*

CareerPhysical HealthRelationshipsSpiritualityMental WellnessLife PurposeFinancesSelf WorthOther
If I had all the power in the universe to change one thing about your life right now, what would it be?*
Is there anything else you think I need to know about you that may assist tailoring your sessions? For example, health concerns, additional needs, disabilities, significant life events, etc. If not, just write 'None'*
Terms and Conditions

1. Services - The Coach and Client consent to engage in an agreed coaching program, conducted via video conferencing. The coach may choose to be available to the client via e-mail and voicemail in between scheduled sessions.

2. Schedule of Fees - The client’s investment is non-refundable. Fees will be invoiced and required to be paid prior to the scheduled session. Each session will run for approximately 1 hour unless otherwise agreed.

3. Confidentiality - All information supplied by the client is confidential. Information will not be given to third parties in relation to the client without their permission, unless the coach deems the client, or any other person associated with the client, to be in a serious or life-threatening situation, in which case the coach is duty-bound to report such information to the appropriate authorities. Such situations may include suicidal tendencies, physical, mental or emotional abuse being committed on or by the client or criminal acts. Please also refer to the Privacy Policy on the website: www.lenorepearson.com

4. Cancellation and Termination Policy - Where it is foreseeable, the client agrees to give no less than 24-hours notice to reschedule a coaching session.
Consent
- I, as the client, understand that I am solely responsible for creating and implementing my own physical, mental and emotional wellbeing choices and actions which may arise from interactions with the coach. As such, I agree that the coach is not, and will not, be liable or responsible for any actions or inactions taken, or for any direct or indirect results from services provided.
- I understand that coaching is not therapy and does not substitute for therapy. It does not prevent, cure, or treat any mental disorder or medical condition. Coaching, in no way, replaces professional medical or psychological assistance.
- I understand that I am responsible for disclosing any medical conditions and mental health diagnoses. The coach is not qualified, nor has any responsibility, to diagnose these.
- I understand that to gain full benefit from the coaching relationship, I need to communicate honestly, act on feedback and assistance provided and invest the time and energy to participate fully.
- I understand that by signing this Intake Form, I am acknowledging that all information is true and correct. I acknowledge I have read, clearly understood and accepted the Terms and Conditions as set out above.
Client Signature*

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Must be signed by a legal guardian if client is under 18 years of age.
Date Signed*

DayMonthYear
Date
Should be Empty:

Client Intake Form and Agreement

Medical Background

Knowing You Better