Rita Maureen Wellness (NBC-HWC)

Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Area Code Phone Number

What do you want most to get from Health and Wellness coaching? *

What concerns, if any, do you have in starting Health and Wellness Coaching? *

What are some of the most relevant stresses in your life right now? How do you typically react/cope with them? *

I feel safe in my home and general surroundings. *

Strongly Agree Agree Neutral Disagree Strongly Disagree

I feel safe in terms of my mental health. *

Strongly Agree Agree Neutral Disagree Strongly Disagree

I have a history of disordered eating/an eating disorder. *

Agree Disagree

I am currently working with a therapist or other mental health professional. *

Yes No

Is there anything else you'd like to share?

I'm investing in: *

12 coaching session package 5 coaching session package 8 coaching/8 Pilates session package

I'd prefer to have sessions... *

Over a phone call Over Zoom May depend on the week

Medical Disclaimer: Health and Wellness Coaching is NOT a substitute for medical guidance or psychotherapy. If you have a serious concern about your health (both physical and mental) that warrants medical attention, please see a qualified health care provider. Health and Wellness Coaching should always be used as a supplement and for fulfillment of your health and wellness goals. Health coaches are not here to give advice, prescribe a plan, or tell their clients what to do. While health coaches may be medical professionals, their function is solely that of health coach. This means that although a health coach may know a lot about health, in this role, their greatest expertise is in the process of sustainable change. Coaches serve as a guide in the client’s journey. The focus is not on disease treatment but rather, the focus is on improving one’s quality of life. By signing this form, you are engaging in Heath and Wellness Coaching with Rita Thompson on the basis of your voluntary consent.

I agree to the medical disclaimer. *

I agree.

Cancellation/Refund Policy: 24-hour notice is requested for cancellation of a coaching session. “No-shows” unfortunately will not be refunded. There are no refunds offered for sessions/session packages, however, the sessions never expire if client wants to use at a later time.

I agree to the cancellation/refund policy. *

I agree.

Confidentiality & Privacy: This coaching relationship, as well as all information (documented or verbal) that the Client shares with the Coach as part of this relationship, is bound to confidentiality by the International Consortium for Health & Wellness Coaching Code of Ethics. The Coach agrees not to disclose any information pertaining to the Client without the Client’s written consent. The Coach will not disclose the Client’s name as a reference without the Client’s consent. Confidential information does notinclude information that the Coach is required by law to disclose.

I understand the Confidentiality & Privacy guidelines. *

I agree.

Client Responsibilities

As the client, I agree to:

1. Honor my scheduled session times and will be on time for each session. I will meet in a quiet place where I have the freedom to share honestly and freely.

2. Be motivated and committed to taking action on my health and wellness goals. I will create the time and energy to participate fully in the program.

3. Communicate honestly, even if what I say is “I don’t want to talk about that.”

4. Tell my coach if the process is not working for me, or I need something else.

5. Understand and agree that I am fully responsible for my physical, mental and emotional well-being during my coaching calls, including my choices and decisions.

I agree to Client Responsibilities. *

I agree

Coach Responsibilities

As your coach, I agree to:

1. Abide by the National Board for Health & Wellness Coaching (NBWHC) ethics and standards of behavior that can be found here: https://nbhwc.org/wp-content/uploads/2019/04/FINAL-Code-of-Ethics-4_15_19.pdf

2. I will be fully present throughout the sessions and devote my time, thoughts, and energy to you during our coaching sessions.

3. Provide encouragement, support, and a space where your client may explore his/her own thoughts, motivations, and decisions.

4. Brainstorm possibilities to promote discovery of new insights.

5. Be consistently supportive of the client as a person and as the one who holds the vision.

Signature in recognition of your receipt and review of this document. *

Clear