Personal Coaching

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Full Name* This field is required.
First Name
Last Name
2
Are you over the age of 18yo?* This field is required.Members are required to be at least 13yo of age. Guardian consent is required to start personal coaching for members under 18yo.
YESNO
3
Date of Birth* This field is required.
Date
Month
Day
Year
4
Gender (optional)
5
Contact Email* This field is required.
example@example.com
6
Contact Phone* This field is required.The primary contact phone number. By entering the following number below, you understand that we may leave voicemails when necessary.
Please enter a valid phone number.
7
Name of Parent/Guardian * This field is required.
First Name
Last Name
8
Parent/Guardian Phone * This field is required.
Please enter a valid phone number.
9
Parent/Guardian Email * This field is required.
example@example.com
10
Parent/Guardian Consent* This field is required.By signing below, the parent/guardian consents to the prospective member's participation in Kinetik, skills classes, groups, and community, and coaching.
Clear
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
What best describes your employment/student status?
Full Time Employment
Part-time Employment
Unemployed
Student
Homemaker
Other
13
What do you hope work on or improve with coaching?* This field is required.
Time-management and Planning
Procrastination
Work performance
Exercise
School/academic performance
Organize my space
Work/life balance
Eating/diet
The noise in my life
Focus/attention
Motivation
Enter a new career
Routine and structure
New habits
Efficiency
Peak performance
Other
14
Tell us more about what you what like to get out of coaching.
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Large
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Small
Ok
Ok
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Is there anything else you would like the coach to know before you get started?
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Normal
Small
Ok
Ok
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How did you hear about us?
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What are your preferred days and times for personal coaching?
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Disclaimer* This field is required.Before you start, it's important to note that Kinetik services (including but not limited to community, classes, groups, and coaching) are for informational, accountability, goal management, and executive functioning skills learning/application purposes. No Kinetik service (or combination of) constitutes the practice of medicine, mental health, or other professional health care services, including the giving of medical or mental health advice. No doctor/patient (clinician/patient) relationship is formed by use of Kinetik services. The use of content and services from this program or linked from this program is at the user’s own risk. The content and services of Kinetik is not intended to be a substitute for professional medical or mental health advice, diagnosis, therapy, or treatment. Users should not disregard or delay in obtaining medical or mental health consultation for any medical or mental health condition they may have and should seek the assistance of health care professionals for any such conditions. Although Kinetik coaches, instructors, and staff may have a clinical license or a professional history in mental health, their scope of services do not extend beyond their role as a coach, and their contact with you does not establish a healthcare professional and patient working relationship.
I understand
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Release of Information* This field is required.Under HIPAA, certain information about a person’s health or health care services is classified as Protected Health Information (PHI). Although Kinetik does not provide health services, your personal coach is required to consult with PCH clinicians for supervision. If you are under the care of a provider at PCH, relevant clinical information may be disclosed from time to time with your personal coach and the Kinetik Coaching Team. The Kinetik coaching team only includes supervised coaches and does not include Kinetik administrative staff. This is to insure proper case management and quality of care. By selecting "I agree" below, you agree to the release of clinical information to and from, Peachtree Comprehensive Health and the Kinetik Coaching Team. Termination of services with your personal coach will nullify this release. Under the circumstance you restart services, this release becomes effective immediately. A Business Associate Agreement (BAA) has been completed enabling this form to meet HIPAA compliance and standards. Peachtree Comprehensive Health includes the following parties: Peachtree Psychiatric Professionals P.C., Peachtree DBT, and The Peachtree Cognitive Center.
I agree
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Code of Conduct Agreement* This field is required.The Kinetik program intends to foster learning, support, and growth through a safe and positive space. Please review Kinetik's code of conduct below. If you have not read them, please read the Circle platform's Privacy Policy and Terms of Service. Anti-Intolerance. Kinetik stands against all forms of dehumanizing or unlawful treatment of others, including but not limited to all forms of cyberbullying, cyber-harassment, hate speech, or threats based on their race, ethnicity, national origin, religion, caste, sexual orientation, sex, gender, gender identity, disability, or immigration status. Be kind and respectful. There's no need to be mean, rude, offensive, or antagonistically political. While it is fine to challenge each other and provide feedback, please avoid disrespectful comments or destructive criticism. If you and another member have a disagreement, make an effort to understand their points of view before you respond to them. And when you respond, strive to resolve disagreements constructively and respectfully.Don't promote, solicit, or spam. There are plenty of places on the Internet for that; this is not one of them. We reserve the right, at our complete discretion, to remove any comments or statements that we or our systems identify as promotions, solicitations, or spam. Keep discussions relevant and reasonable. We do not want you to feel limited or constrained to any specific topics or ideas within community discussions. However, topics or ideas that have no apparent relation to Kinetik's focuses or objectives will likely not be relevant.Respect the privacy of others. This is a private space for members who are paying for our service. In general, we'd love for everyone to be as open and transparent as they want to be, but we want their privacy to be respected. Please do not share anyone’s nonpublic personal information on our platform. Do not use our platform to dox, extort, harass, or spread false and disparaging rumors about others. What happens if someone violates the code of conduct? We expect members to abide by the code of conduct with the Kinetik skills classes, groups and community. If we identify a violation, we may, at our discretion, opt to delete it without further comment and without notifying the person we might have concluded crossed the line. A first-time violation may receive a warning from us. A second-time violation may receive another warning. If more than two violations occur during a short period of time, such as within one month, we may take further action. Violations of our Anti-Intolerance guidelines are most likely to result in a permanent ban from Kinetik. Please select "I agree below" if you have read, understand, and agree to these terms.
I agree
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