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The Emotional Reset - Coaching Program

Client Intake Form

Birthday
Day
Month
Year
Multi-line address
1. Have you worked with a coach before?
Yes
No
2. Are you experiencing any issues that require mental health services?
Yes
No
3. Are you currently seeing a therapist?
Yes
No
3. Do you have any medical or physical conditions I should be aware of?
Yes
No

On a scale of 1-10 how satisfied are you in the following areas

Family
Relationships
Emotional
Career
Health
Recreation
Financial
Personal Growth

Disclaimer


Role of a Life Coach:

Life coaches are not licensed healthcare providers and do not provide medical advice or engage in patient diagnosis. Coaches do not treat or otherwise counsel those with mental illness. Life coaches work with clients to assess their current situations and help the client make concrete plans for achieving their goals.


Coaching vs. Therapy:

Coaching is not therapy.

No guarantees regarding outcomes are made, and the client acknowledges that results vary based on a multitude of factors beyond the coaches control. The client acknowledges that the coach, nor their respective companies are legally responsible for any action, or inaction, the client takes in relation to their coaching experience. Coaching is for personal growth and educational purposes only. Coaching is not suited for psychological issues.

At any point in the coaching relationship, should the client feel as though

they are in need of mental health services, the client agrees to promptly

inform their coach.

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