Coaching Application

Full Name*

First NameLast Name

Email*

Phone Number*

Area CodePhone Number

E-mail*

Confirm Email*

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Occupation

Birthdate*

MonthDayYear

Martial Status*

Do you have children?*

Yes, and they live with me.Yes, but they don't live with me.No

Which coaching plan have you decided on? Payment is not due until application is processed and approved. Payment plans available for Recovery Programs.*

Session to SessionIntroductory Recovery ProgramIntermediate Recovery ProgramIntensive Recovery Program

Briefly describe your life story to date. Share as little or as much background information as you would like. *

Please briefly describe why you are seeking coaching services and what you hope to achieve? Please be as specific as you can.*

Have you been coached before? What was your prior experience like?*

Are you now or have you ever been in counseling or therapy? If yes, please explain.*

If you are currently in counseling, do you give permission for your coach to work in tandem with your counselor in order for you to receive the best possible outcome from your coaching journey? You will need to give your counselor permission to reach out to your coach in order for this to happen.

YesNo

Describe your faith. What is your relationship with God like? In what ways do you sense He might be challenging you, nudging you, or trying to get your attention?*

What are some major things happening in your life right now?*

How would you like your life to be different one month from now? One year from now? Five years from now?*

What is getting in the way of achieving these changes or goals?*

Name 3 things in your life you are procrastinating on in your life right now.*

If we worked together, in what ways might you sabotage me as your coach or your own success? In what ways can I help you to not do this? *

What are some of your concerns or insecurities about being coached?*

Is there anything else you would like to add?

How did you hear about coaching with Crystal Renaud Day?*

Terms and Coaching Agreement (applies to all coaching types)*

I understand that Crystal Renaud Day is a certified coach and master level pastoral counselor, but not a licensed therapist. She holds no responsibility for any harm I may cause to myself or othersI understand that Crystal Renaud Day must report to proper authorities any information that I disclose that indicates that I may be a harm to myself or othersI understand that Crystal Renaud Day may assign homework to be reviewed at each session and failure to complete homework could result in termination of remaining coaching sessions without refundI understand that if for some reason I am unable to complete pre-paid coaching sessions, no refund will be provided unless extraordinary circumstances applyI understand that if Crystal Renaud Day becomes unavailable to complete our coaching session I will be refunded for any pre-paid sessions remainingI understand that each coaching session will be 50 minutes in length on a specific date and time. Being late to the session will cut into my total session length.I understand that coaching is not a replacement for mental health counseling and should it deem necessary, I may be referred to a mental health professional and coaching may be terminated with refund or sessions may be postponedI understand that coaching is a confidential relationship and Crystal agrees to keep all information strictly confidential and HIPAA compliant, except in situations that violate the law or harm to self or others is disclosed

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