Health Coach Intake Form

Date
Date
Name *
Name
What other areas in your life would you like support in?
Check all that apply
What areas in your life would you like to improve?
Check all that apply
Agreement
Please read each point below. Checking the radio button at the end of this form confirms that you understand each statement in the agreement as outlined below and that you will meet your contractual obligations as outlined below.
1. Once sessions and session packages are paid for the monies become nonrefundable and non-transferable. Credit will be left on account for one year.
2. Sessions are based on a fifty-minute hour.
3. Please show up on time. Out of respect for other clients, the sessions must also end at the scheduled time.
4. 24 hours notice appointment cancellation is considered the minimum. No-shows will be billed half of the session rate or a session will be deducted from package. Eg. In the event of a no-show the client may choose to either deduct one session from the package or pay one half of the session fee. Please inform us of any schedule changes.
Disclaimer
Coaching may or may not include any of the following modalities to expedite change within the client and aide in relaxation: Visual imagery, creative visualization, hypnosis, Neuro Linguistic Programming, stress reduction processes and techniques for the purpose of vocational and/or a vocational self-improvement.
I understand that the coaching I am receiving is not a substitute for medical or psychological or medical care.
Additionally, I should and will continue any present medical treatment and consult my regular family Physician for treatment of any further illnesses.
Required Field *