Healthy Habits with Miss Heidi™️
Participation Waiver And Release Form
Participant Name
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First Name
Middle Name
Last Name
DOB
*
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Month
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Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Today's Date
*
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Month
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Day
Year
Date
Preferred Meeting Date
*
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Month
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Day
Year
Appointment confirmation will be sent 1 week before.
Preferred Meeting Time
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Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
Program descriptions can be found on our website, www.missheidistattoo.com/hhwmh
Program Selection
*
Please Select
1 hour evaluation and 1 hour of coaching - $150
1 hour evaluation and 6 Week program package - $1,040
1 hour evaluation and 10 Week program package - $1,500
Couples Package - $850
Program descriptions can be found on our website, www.missheidistattoo.com/hhwmh
Payment Amount
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Three Primary Goals
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I acknowledge that confidentiality is only in question if ordered by the court.
I understand and agree that suggested protocols are not medical advice and under no circumstance should be taken as such. Any and all questions concerning physicdal and/or mental health will be directed to my personal choice in medical and/or psychiatric professional.
I agree that payment persuant to the purchase of any protocol offered by Healthy Habits with Miss Heidi is non-refundable regardless of outcome.
I agree that two consecutive cancellations will result in forfiet of the afore scheduled session. Failure to notify my coach within 24 hours of scheduled meeting will also result in forfiet.
Participant Signature
*
Back
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Discovery Meeting
1. Current Situation
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2. Goals (Answer A & B)
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(A) Top Three Goals (B) Commitment Level
3. Obstacles (Answer A, B & C)
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(A) Time (B) Limiting Beliefs (C) Obligations
4. Identify Negative Self Talk
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5. "Surrender to Win" - Identify Current Identity Statements
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6. Identify physical and/or mental health limitations
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7. Desired outcomes and expectations
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8. Set incremental goals
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9. Limiting Historical (Personal) experiences
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10. Emotional Trauma
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11. Establish personal responsibility
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12. Assessment of ability to delay gratification
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Should be Empty: