Name
*
First Name
Last Name
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Date of Birth
MM
DD
YYYY
Enneagram Type
*
1
2
3
4
5
6
7
8
9
What main concerns would you like to address in our work together?
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What practices or interventions have you already tried for these concerns or to improve your wellbeing overall?
*
What are some of your goals you wish to achieve through this process?
*
Please read the following disclaimer:
By checking 'I agree' below, you understand the following:
Although it is my intent to hold space for whatever you bring to each session, I am not acting as a mental health professional. Our coaching sessions do not provide therapy or attempt to diagnose, treat, prevent, or cure any physical, mental, or emotional issues. If you are facing crisis, particularly if you are experiencing severe depression or anxiety that is leaving you incapacitated, please reach out to a therapist or emergency services in your area.
I will protect your information as confidential unless you state otherwise in writing. If you report child, elder abuse or neglect or threaten to harm yourself or someone else, you understand that necessary actions will be taken and your confidentiality agreement limited in this capacity.
The use of technology is not always secure and you accept the risks of confidentiality in the use of email, text, phone, Zoom, and other technology.
You agree with the following waiver: I hereby release, waive, acquit and forever discharge my Coach, any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of acts or omissions by myself or by my Coach as a result of the advice given by my Coach or otherwise resulting from the coaching relationship contemplated by this agreement. I further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents.
Cancellation Policy
I understand that no-shows and cancellations within 24-hours of appointment time will result in a charge of $50.
