Emily Arin Coaching Intake

CLIENT INTAKE FORM
Name*

First NameLast Name
Email*
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Cell Number*

Area CodePhone Number
Address*

Street Address

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CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
How did you hear about me?*
MEDICAL INFORMATION
Do you have any current medical or mental health diagnosis? If yes, please describe.*
Are you on any prescribed medication from a doctor? If yes, please describe.*
Do you receive any other care, such as counseling, acupuncture, chiropractic, etc.? If yes, please describe.*
HISTORY

Feel free to answer in short, bullet-point sentences rather than long narratives. This part of the intake is just to get the gist of what beliefs might still be blocking you from fulfilling your current dreams.
Please list/describe any significant life events, challenges, and triumphs. *
What do you think you concluded about who you are or what your value is based on your upbringing and family of origin? *
Please name any patterns that persist in your life that seem unhelpful and/or hard to shake or transform--these can be mental, emotional, spiritual, physical.*
Your Vision!
What is your ideal outcome from our work together? If it's helpful, you can list top 3 goals/dreams for the coming year. OR, if you're more into stories and narratives, paint me a picture of your dream life. Please go big and wild here!*
It is helpful for me to know your spiritual and/or religious orientation and name(s) for what you conceive of as larger than your individual self. For example, God, Goddess, Nature, Life Force, Divine, Source, Cosmic Wonder, etc. It is my experience that our healing and growth work is amplified by deepening this personal relationship and feeling supported by it. *
24-Hour Cancellation Policy

If you need to cancel or reschedule your session, please let me know as soon as possible in advance. I require notice at least 24 hours prior to your scheduled appointment. Otherwise, full session fees will be charged.
Payment Policy

Payment for session packages is made prior to our first session. 2-payment plans are available. Payment can be made via Venmo (@Emily-Snider-10), Zelle (emilyasnider@gmail.com), or PayPal (which accepts credit cards).
INFORMED CONSENT
I understand that the Transformational Coaching and PSYCH-K® Sessions provided by Emily Arin Snider are intended as a form of support on the path to wellbeing.

As a certified practitioner, Emily Arin Snider employs mind-body-energy based approaches including PSYCH-K®, Tapas Acupressure Technique (TAT), somatic mindfulness, coaching conversations, felt-sense focusing, and meridian tapping.

I understand these are gentle and complementary approaches for facilitating wellbeing using my body and mind's own wisdom and self-healing ability.

I understand that the sessions and the techniques used are NOT a substitute for medical diagnosis or treatment from a licensed healthcare provider.

I am aware that
- Emily Arin Snider is not a doctor.
- Emily Arin Snider is not a licensed mental health practitioner.
- Emily Arin Snider does not make medical diagnoses nor prescribe medications and nothing said during the course of the sessions should be construed as such.
I understand that by digitally signing this Informed Consent, I am assuming full responsibility for my physical, emotional, and spiritual health. I agree to release and hold harmless Emily Arin Snider from any and all liability in connection with these sessions.

I understand that all information contained within this form is confidential, and will not be released without my written consent.

I understand that a 24-hour cancellation/rescheduling notice is required for any session or full-session charges will apply.

With my digital signature below, I hereby agree to the terms and conditions of this form and authorize Emily Arin Snider to provide me with Transformational Coaching and PSYCH-K® Sessions.
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CLIENT INTAKE FORM

MEDICAL INFORMATION

HISTORY

Your Vision!

24-Hour Cancellation Policy

Payment Policy

INFORMED CONSENT