CPC Intake

After finishing, please click here to make your payment. This payment is non-refundable and will be credited toward your package or membership plan. We require it prior to your intake meeting.

Student Name*

First NameLast Name

Student Date of Birth*

Date

Student Pronouns

Student Phone Number

Area CodePhone Number

Student Email*

example@example.com

Address*

Street Address

TownCity

PostalCodeCountry

Student Primary Health Care Provider & Phone Number:

Student Mental Health Care Provider & Phone Number:

Parent 1 Name*

First NameLast Name

Parent 1 Phone Number*

Area CodePhone Number

Parent 1 E-mail*

Parent 1 occupation

Parent 2 Name

First NameLast Name

Parent 2 Phone Number

Area CodePhone Number

Parent 2 Email

example@example.com

Parent 2 occupation

Parent Marital Status

Please answer the following questions:*

	Yes	No
Does the student have ADHD?
Does the stduent have EXECUTIVE FUNCTION CHALLENGES?
Does the stduent have a history of Brain Trauma?
Neuropsychological or Psychological Evaluation Completed?
Has the student ever had special accommodations per an IEP/504 plan?
Is the student currently in Therapy?

Name of Diagnostician and Date of Diagnosis:

Are there any known disabilities or co-morbid conditions? If yes, please explain:

Is the student currently taking medication for ADHD, depression, and/or anxiety? If yes please list:*

Any other medical conditions, including current treatment and medications:*

Is the student currently working with a tutor? If yes, please list which days and subjects

Please upload any school plans and psychological evaluations

Browse Files

Our newsletter serves as a primary means of communication, providing clients with essential information such as registration schedules, required documentation, updates to services, closures, and other important announcements.

Clients may choose between the following options:

Essential Updates Only – A concise version containing only critical information and reminders.
Full Newsletter – Includes all essential updates, along with additional content such as upcoming events, informational articles, staff spotlight, and special announcements.

CHOOSE NEWSLETTER OPTION*

COACHING CONTRACT

Appointments:

All Client services are by appointment only. Connected Pathways Coaching will be closed during holidays and break, please see calendar on website. Coaching can take place on some of the listed holidays, if mutually agreed upon by client and coach.

There will be no refunds for missed appointments. Replacement of appointment will be offered with virtual office hours. Summer schedule is at the agreement of both parties, but same cancellation policies apply. If last appointment of services is cancelled, and office hours are not attended, the balance will not be refunded.

PAYMENT:

Payment for packages is due in full or payment plans that are due by the 15th of the month, by check or credit card. Any payment not received by the 22nd of the month will have an additional 5% late fee added.

Payment for Membership instant booking is due prior to the booked session, and the Membership fee is due by the 15th of the month.

PRIVACY:

Coach agrees to maintain complete anonymity of all Client information disclosed or received from any third party unless permission is received from a Parent. If it is necessary for the Coach to gain access to information from schools, therapists, physicians or other professionals, Coach will provide a standard information release form for Parent’s signature.

However, the terms of anonymity shall not apply where failure to disclose may be, in Coach’s sole discretion, in violation of any law or may involve information regarding certain crimes that have either been committed or Coach believes may be committed; may be dangerous or possibly cause harm to the physical or emotional well-being of Client or anyone else, or when such information is subject to subpoena. This provision will survive expiration or termination of the Agreement.

Coaching Process and Disclaimer:

A) Coaching is designed to guide the Client to learn how to consistently achieve results and make purposeful choices. Client agrees to communicate honestly, be open to feedback and assistance and create the time and energy to participate fully in the coaching program. However, due to the totally subjective nature of the work, Client and Parents understand and agree that Coach makes no guarantee as to the results Client will achieve, nor is Coach responsible for the results achieved by Client from the coaching.

Client and Parents understand that coaching is NOT therapy and does not substitute for therapy if needed, and does not prevent, cure, or treat any mental disorder or medical disease.

B) Parents hereby authorize Connected Pathways Coaching, LLC to work with Client in their capacity as a Coach. Parents understand and agree that Connected Pathways Coaching, LLC is prohibited from disclosing to Parents any detailed information obtained from Client during the coaching process, except as provided in paragraph 4 (Privacy) above. However, Client and Parents understand and agree that Coach may provide general updates, the extent of which is to be determined by Coach in Coach’s sole discretion, to Parents with respect to Client’s progress, changes in appointment times, missed appointments, client e-mail check-ins, and phone drop-offs.

Once we’ve had the intake meeting, we’ll outline the coaching services that make the most sense for your needs, along with session length and pricing.

I have read and understood this agreement, including the terms and conditions, and agree to be bound to them.

Please do not forget to click here to make payment

Signature*

Intake Paperwork