Grief Support Client Intake & Waiver Form
We hold your story with reverence. Please complete this form to help us better understand your unique journey andhow we can support you.
Client Information
Full Name
*
First Name
Last Name
Pronouns
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Grief History
Who or how are you grieving?
*
Type of Loss
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Anticipated loss (palliative/terminal)
Miscarriage or infertility
Death of a loved one
Pet loss
Diagnosed Terminal Illness
Other
Type of Loss - Other
*
Date of Loss
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-
Month
-
Day
Year
Date
How did the loss occur?
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Were you present at the time of loss?
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Yes
No
Prefer not to answer
Emotional Support
What emotions are most present for you right now?
*
Do you feel supported by others in your life right now?
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Yes
No
Unsure
Optional notes about support from others
*
Have you experienced any of the following since your loss?
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Sleep disruptions
Changes in appetite
Fatigue or body heaviness
Anxiety or panic
Physical pain without clear cause
Difficulty concentrating
Numbness or disconnection
Other
Experiences since loss – Other
*
Are you currently receiving any mental health or medical support?
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Yes
No
Optional – Name of practitioner or type of support
*
Support Preferences and Additional Notes
What kind of support are you seeking through these sessions?
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Gentle listening space
Spiritual or intuitive support
Tools for coping and integration
Grief Reiki healing
Guided meditation
Other
Support seeking – Other
*
Is there anything else you'd like to share before we meet?
*
Understanding the Difference Between Therapy and Life Coaching
There is a distinctive difference between therapy and life coaching: Therapy focuses on helping people heal from past traumas, emotional issues, and mental health problems. Therapists are trained to diagnose and treat these issues, often looking at your past to understand and resolve current problems. Life Coaching is about helping people set and achieve personal or professional goals. Life coaches focus on the present and future, providing guidance and motivation to help you reach your goals. They don’t diagnose or treat mental health issues but help you improve specific areas of your life. In short, therapy is about healing and understanding your past, while life coaching is about setting goals and improving your future.
Liability Waiver & Acknowledgment
I acknowledge that the grief support session(s) I am receiving through Purple Phoenix Wellness are offered by a certified Grief Life Coach and not a licensed therapist, psychologist, or medical professional. I understand that these sessions are intended to provide emotional support, space for reflection, intuitive guidance, and gentle healing practices. They are not a substitute for mental health counseling, diagnosis, or treatment of any kind. By signing this waiver, I agree that I am fully responsible for my own well-being during and after the session(s). I release Naomi MacLaren (Purple Phoenix Wellness) from any and all claims, liabilities, or damages arising from my participation in these grief support services. I affirm that I am mentally and emotionally stable enough to engage in life coaching and support services and understand that if I require deeper psychological or psychiatric care, I will seek that through the appropriate channels. I agree and consent to receive support.
By submitting this form, you acknowledge that your information will be held in confidentiality and used solely for the purpose of grief support services through Purple Phoenix Wellness. This is a sacred, non-judgmental space of care.
*
I agree and consent to receive support
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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