Intake Form

Intake Form

Compassionate Inquiry
Client Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
May I communicate with you via phone?

YesNo
May I communicate with you via text messaging?

YesNo
May I communicate with you via email?

YesNo
Primary Care Provider
Phone Number
Emergency Contact Information
Name

First NameLast Name
Relationship
Phone Number

*If child or teen under age 18
Legal guardian Name

First NameLast Name
Relationship to client
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Questions

Answer to the best of your ability
Who referred you to me or how did you find me?
What prompts you to seek help at this time?
If we were to be successful with CI, how would your thinking, feeling and behavior change, if at all? How would your life be different?
List any problematic physical or mental conditions you have:
List medications you are taking and what they are for:
If you had previous therapeutic services, what was most helpful about it? Least helpful about it?
Is there anything else that you think might be important for me to know about you? If yes, what is that?

Confidentiality and Informed Consent for Services
As you consider participating in Compassionate Inquiry services, it is important that we have a shared understanding about the conditions we agree upon.

Certain principles are maintained during a Compassionate Inquiry session. These are:
- The client is encouraged to bring a specific intention to each session.
- The client determines how much to engage in the session and may request to pause or stop at any time.
- The practitioner/coach may interrupt the client during the session to bring the client into awareness of the present moment and to body sensations and emotions.
- The practitioner/coach follows the subtle cues of the client.
- The practitioner/coach may slow the pace of the session.
I have completed The Compassionate Inquiry® Professional Training and Mentorship Program.

I have also been certified by the International Coaching Federation as a PCC (Professional Certified Coach).

As a CI practitioner and coach I have an ethical responsibility to protect your confidentiality. That means that what we discuss in your sessions is not shared with anyone unless otherwise agreed upon in writing. There are, however, important exceptions to confidentiality, where information could be released without your consent. This could happen if:
- I believe that you could be a risk or a danger to yourself or others
- I have received information leading me to suspect that a child may be at risk of being abused or neglected
- I am given information that a health care professional has sexually abused you
- Records are subpoenaed by a court of law
I will speak to a third party (i.e. family doctor) on your behalf if you would find that helpful, and if you communicate this request in writing.

You are responsible for the total charges incurred for each visit. I accept checks, cash, Zelle, Venmo or PayPal. I do not currently take insurance.

I am accountable to you and to the Compassionate Inquiry Code of Ethics as well as the ICF Code of Ethics. If you have any complaints about my service, you are invited to let me know. I am always interested to know your feelings and encourage dialogue.

Although there can be many benefits to Compassionate Inquiry sessions, it can also be a difficult process that leads to the opening up of emotional pain. This may disrupt your relationships and daily activities. As I accompany you in your CI journey, I will endeavor to create an attuned and safe container for any difficult material to be processed. Please discuss with me any concerns that you may have.

I book sessions in advance, and I do offer crisis response, but if you require immediate emergency support dial 911 or go to the nearest emergency department.

I understand that things come up, and choices need to be made which can change your schedule. I respectfully request a 48 hours’ notice to cancel or reschedule your session. Charges apply to sessions cancelled within 24 hours.
I have read and understand the above Confidentiality and Informed Consent statement, I hereby consent to Compassionate Inquiry services.
Date

MonthDayYear
Date
Signature

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Informed Consent to Recording
One of the things that set me apart from other practitioners and coaches is the use of videotape. Attention to detail and refined attunement is called for in this work while a great deal of verbal and non-verbal material surfaces during sessions. This can sometimes be difficult to see all at once. Thus, I find that the use of videotape to review what took place during a given session with qualified colleagues and supervisors greatly enhances my ability to better help you, in that I often gain valuable information that can deepen and accelerate the process of our work. In my experience, my ability to review a videotaped session can make a very positive difference for you. In short, consenting to having your sessions with me video recorded helps me to help you better. The time and resources I apply to reviewing your sessions is considered part of the services and is offered to you at no additional cost. The videotaping itself is unobtrusive, and I find that most people quickly forget about the taping process. Please keep in mind:

· You can ask to stop and have the recording discontinue at any point in time during a session.

· You can revoke this authorization at any time, by written request to Rakel Kieding.

Please indicate your permission to have your Compassionate Inquiry and/or coaching sessions recorded by me, Rakel Kieding, in the following section:

I agree to the indicated procedures associated with my sessions with Rakel Kieding. I agree to my practitioner/coach making audio/video tapes of our sessions and understand that these recorded sessions may be used for teaching purposes in various situations pertaining to training, supervision, and learning contexts. The recordings may also be used for certification and re-certification review by the certification team of Compassionate Inquiry Inc, or the International Coaching Federation. If received by Compassionate Inquiry Inc the videos will be stored privately online by them in a secure platform called Submittable. Compassionate Inquiry Inc is responsible for the security of this information once the video is in their possession. For re-certification review by the ICF the tapes will be stored on the secure cloud storage platform Google Drive by Rakel Kieding and accessed by the ICF re-certification team.

Any person involved in tape review is bound to the same ethical principle of confidentiality as professionals providing counseling. The tapes are property of Rakel Kieding, and will not be available for viewing by you/the client.
Date

MonthDayYear
Date
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IF THE CLIENT IS A MINOR (UNDER 18 YEARS), HIS/HER PARENT OR LEGAL GUARDIAN MUST ALSO SIGN THIS AGREEMENT. xt...
Date

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Date
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Intake Form

Emergency Contact Information

Questions

Confidentiality and Informed Consent for Services

I have read and understand the above Confidentiality and Informed Consent statement, I hereby consent to Compassionate Inquiry services.

Informed Consent to Recording