Coaching Services Intake Form-AFRIKAN GODDESS LAIR LLC Logo

  • Coaching Service Intake Form

    Provided by Afrikan Goddess Lair, LLC
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  • RENDER COACHING SERVICES AGREEMENT

    1. Parties
    This COACHING CONTRACT (“Contract”), dated * , is made by and between Afrikan Goddess Lair, with an address of 304 E. Pine Street, Ste 1167 Lakeland, FL 33810 (“Coach”), and *. In consideration of the mutual promises and covenants in this Contract, of which the receipt and sufficiency are hereby acknowledged, the parties further agree to the terms as follows:
     
    2. Services
    The Coach agrees to provide Wellness Coaching Services (“Services”) to the Client in preparation for the Client to achieve the health related goals and results the client seeks. The client enters into the coaching agreement with the understanding that the Client is responsible for creating their own results as it is the responsibility of the Coach to help the Client achieve the health related goals and results the Client seeks.
    The Services include but are not limited to:
    *Preparation of customized herbal blends
    *Biweekly check in via Zoom or phone call
    *Guidance and coaching through the detoxing/cleansing process
    *Uplifting Affirmations to recite daily during your journey
    *Fitness and movement plan
    *Preparation of customize alkaline plant based meal
     
    3. Responsibilities
    Client
    It is expressly understood that it is the Client’s responsibility to follow the strict guidance of the Coach without any variance. The Coach is bound to the responsibilities given to the Coach if and only if the Client adheres to the Client’s responsibility. A separate and explicit responsibilities addenda will be given to the Client that will be bound and enforced in accordance to this Contract.
     
    Coach
    It is expressly understood that it is the Coach’s responsibility to follow the strict guidance of the Coach’s responsibilities addenda without any variance. The Coach is bound to the responsibilities given to the Coach if and only if the Client adheres to the Client’s responsibility. A separate and explicit responsibilities addenda will be given to the Client that will outline the given responsibilities of the Coach to be bound and enforced in accordance to this Contract.
     
    4. Term
    This Contract will be effective on and will continue until 11:59pm on . The Contract may be terminated earlier by either of the Parties involved for any reasons determined valid by both Parties with at least 15 day notice and may also be extended with prior notice of at least fifteen (15) days.
    5. Payments
    Payments are due within 24 hours of contract execution. There is a three (3) day grace period for payment to be received. If payment is not received by 12p on the fourth day, there will be a $100 late fee. If full payment or balance of payment is not received by the 15th day after contract execution, Afrikan Goddess Lair will submit delinquent accounts to a professional collection agency. Payments may be rendered by cash, cashier’s check, money order, debit card, credit card, Zelle® transfer, CashApp® transfer. No refunds will be given. Client is responsible for all Afrikan Goddess Lair’s service fees and any additional expenses incurred on behalf of Client including but not limited to delivery fees and notary services. This agreement will be considered breached if any payment is returned by a financial institution or not received by its due date and full action will be taken by Afrikan Goddess Lair to receive payment or balance of payment.
     
    6. Transparency
    The Client is encouraged to be transparent to the Coach in the coaching sessions, and the Coach is expected to diligently provide appropriate Services corresponding to the topic brought up and about by the Client in the coaching session.
     
    7. Non-Disclosure And Intellectual Property
    The Client and the Coach shall not disclose to any third party any and all information relayed and discussed during each coaching session unless disclosure is reasonably required. Such reasonable disclosure shall be subject to the prior written approval and consent from the other party. Coach shall be solely and exclusively entitled to any right, title, and interest in and to all or any intellectual property generated in its performance of this Agreement, including but not limited to copyrights, patents, know-how, trade secrets and the like. Client shall not attempt to copy, duplicate or otherwise distribute these intellectual property.
     
    8. Confidentiality
    Due to the medical and personal nature of the Coach’s services, the Coach WILL NOT disclose any personal information to any third parties, including other medical personnel, without the explicit and written permission of the Client. This written consent must be legally notarized and delivered to Coach via mail and/or a secure online channel.
     
    9. Entire Contract
    This Contract constitutes the entire and final agreement between the Coach and the Client and will supersede any other prior agreements or contracts.

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  • INFORMED CONSENT, WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK FORM

    Below is a legal waiver between the Practitioner and the client stating that the client will not sue the Practitioner in the event that something undesired occurs. Filling out this waiver is required to receive products or services from the Practitioner.
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  • Yoni Steam Client Information

  • Contraindications

    There are times when steaming would not be beneficial for a woman. As a first step, let's check and be sure that you are safe to steam.

  • Please Mark Any of the Following Hard Contraindications that Apply

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  • Important

    The above "Yes" replies indicate that vaginal steaming is contraindicated and it is not recommended to steam at this time. It is not safe and could result in negative side effects such as the onset of bleeding or a miscarriage. Steaming should not be done at this time.
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  • IMPORTANT

    If you are using the above birth control methods, it may be possible that vaginal steaming could cause a birth control failure. Steaming is not recommended unless you are okay with using a backup form of birth control or you are not concerned about your birth control failing. 

    If you are having a burning itch, the warmth from the steam could be uncomfortable since there is already so much heat in your body. In this case, you could try doing a sitz bath with cooling herbs. It is also recommended to seek treatment from an acupuncturist to address the underlying imbalances causing the burning itch. Once the burning itch subsides, you may proceed with a vaginal steam.

    If you have had a uterine ablation procedure (to scar over the uterine walls) it may be possible that vaginal steaming will clear the scar tissue which would reverse the surgery. If you are okay with reversing the surgery, then feel free to proceed with vaginal steam. 

  • Steam Sensitivities

    Some women are very responsive to steam and it can cause a physiological response. If you are in this category, then it is okay to steam, however your practitioner will adjust your steam session and herbs so that it suits you. Let's see if you have any sensitivities.
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  • The above "yes" replies indicate steam sensitivity in which case a mild 10 min set up without an electric burner should be used. Under no circumstances should clients who have sensitivity use an advanced setup with an electric burner.

  • No Periods

  • Herb Selection

    It is best to select herbs suitable to your constitution. Your practitioner will use the info from this intake form to select s suitable herbal steam formula for you.
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  • If there are any "Yes" signs for the Gentle herbs this formula will always be the best choice.

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  • Cloaking

    When steaming, it is often common to wear a cloak to make the entire body sweat and thereby enhance the detoxification of the steam session. A cloak is often a blanket put over the entire body or a thick robe. Cloaking is not recommended if the body already has excess heat. Let's check to see if you have any signs of excess heat.
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  • Yes answers indicate excess heat in which case cloaking is not necessary. Instead, use a towel, light robe, steam gown, summer dress or light wrap-around fabric.

  • What to Expect

  • Steaming is a cleanse. Some of the possible signs the vaginal steaming is working is if you experience the following: urge to urinate while steaming, brown discharge after steaming, increased clots or cramps during the next period, increased dry cramps, increased irregular vaginal discharge (white, green, thick, clumpy) emotional release, periods that come earlier or later than expected. All of these signs are a normal part of the cleansing process and these signs should go away once the cleanse is complete. Please note these changes and inform your practitioner.

  • Best Practices

  • 1) Go to the bathroom directly prior to vaginal steaming.

    2) Learn proper period care. Avoid tampon use and instead use cotton pads or period panties. The period is a uterine cleanse and if you support it, the clots can easily clear out. Plugging up with tampons, prevents the old residue from clearing out and that is often the cause of cramping. It is also important to rest during the period and to eat the right foods. 

    3) Increased vaginal discharge can be addressed by using cotton underwear liners and peri-bottle throughout the day to clean mucus off the skin. 

  • Caution Signs

  • If steaming causes a rash, bumps, headaches, itchiness, diarrhea or the onset of fresh spotting or inter-period bleeding, this could be a sign that your steam plan or herbs might need to be adjusted or that there is an allergic reaction. If these signs occur, please let your Practitioner know so they can adjust the steam session as necessary or make a referral.

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    In most cases using a mild steam session and custom herbs will prevent any of the above signs from happening so it's very important that you give honest answers in this intake form so that the Practitioner can set up a steam session that will fit your needs.

     

  • THIS AGREEMENT is made between Tiffany Collier Mcleod and Afrikan Goddess Lair, LLC (as indicated in the practitioner section) and Client (as typed in the field above) ("I") (collectively the "Parties").

    I have purchased or am receiving complimentary steaming services, products or a consultation from Afrikan Goddess Lair, LLC (the "Products and/or Services"). 

    I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in, or cause me to have an adverse reaction to, the Services, including but not limited to preterm pregnancy. I affirm that I have reviewed the "Best Practices" and other Information provided to me by the Company or its agents. I further affirm, that all information provided to Company by me is accurate and complete and I understand that failing to provide information may result in a greater risk of injury. I acknowledge that my purchase and participation in or use of the Products and/or Services is voluntary and I do so entirely at my own risk. I acknowledge that I have approval from my doctor or medical professional to use or receive the Products and/or Services or I yield that requirement and take responsibility for my own medical decision making.

    I understand that results may vary from person to person. I understand that I may react adversely to the Products and/or Services and they may result injury to me. Side effects include, but are not limited to, rash, bumps, headaches, itchiness, diarrhea, increased vaginal discharge, cramping or the onset of fresh spotting or inter-period bleeding. If I elect to continue Products and/or Services after such results, I will alert Company to issues so that the Products and/or Services may be adjusted, or a referral can be made. I expressly agree that all risk of injury that I undertake as a part of the Products and/or Services is undertaken at my sole risk. 

    I further expressly agree that I will not use any equiptment related to the Products and/or Services improperly. If equiptment is located on the Company premises that is not used as part of the Services, I expressly agree that I will not use the equiptment and release Company, its agents and employees from any claim, demands, injuries, damages, actions, or causes of action, that could occur from my inappropriate use of such equiptment.

    I also understand and agree that all information provided before, during or after the Products and/or Services is for informational purposes only and is not a replacement for medical advice from a physician or pediatrician. The Products and/or Services and information provided therein does not replace the relationship between physician/therapist and a client in a one-on-one treatment session with an individualized treatment plan based on their professional evaluation. The Products and/or Services and any information therein are provided "as is" without any representations or warranties, express or implied.

    I will not rely on the Products and/or Services as an alternative to advice from my medical professional or healthcare provider and I will never delay seeking medical advice, disregard medical advice, or discontinue medical treatment as a result of any information provided before, during, or after the Products and/or Services. I understand and agree that all medical related information is for informational purposes only. 

    Company, its agents and employees, shall not be liable to me for any claims, demands, injuries, damages, actions or causes of action to my person or property arising out of or connected with the Products and/or Services and the premises where the Products and/or Services are located. I expressly release Company, its agents and employees from all such claims, demands, injuries, damages, actions, or causes of action, and from all acts of active or passive negligence on the part of Company, to the extent such a release of negligence is permissible by law.

    I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during the Products and/or Services. In the event of sickness, accident, or injury, I authorize Company and its representatives to obtain, on my behalf, emergency medical treatment at my expense.

    This Agreement shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. This Agreement shall be construed and enforced according to the laws of the State of California and any dispute under this Agreement must be brought in this venue and no other. 


    I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I UNDERSTAND AND AGREE THAT I AM GIVING UP LEGAL RIGHTS BY SIGNING THIS AGREEMENT AND THAT I AM DOING SO VOLUNTARILY, FREELY, UNDER NO THREAT OF DURESS, WITHOUT INDUCEMENT, PROMISE, OR GUARANTEE BEING COMMUNICATED TO ME. THE SIGNATURE BELOW IS PROOF OF MY INTENTION TO EXECUTE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY TO THE FULL EXTENT OF THE LAW. 

     

    My printed name and date below represent my signature. 

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  •  If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.

     

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  • End of Client Section

    Thank you so much for all the information. This is the end of the client intake form. Please mark submit below to send this information to your Practitioner.

  • Thank you so much for all the information. This is the end of the client intake form. Please mark submit below to send this information to your Practitioner.

  • Beginning of Practitioner Section

  • Practitioner Section

    PRACTITIONER USE ONLY

  • Vaginal Steam Plan

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  • All done! If you would like to save a PDF version of this intake form please click "Print Form" and save a PDF file before you hit the submit button. 

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