Confidential Intake Form
It is vital to our working relationship, that you answer these personal questions to the best of your It is vital to our working relationship, that you answer these personal questions to the best of your knowledge. They are designed to help me get acquainted with you and I use multiple modalities including Gene Keys, Human Design, EFT, Psych-K and Life Coaching skills to best serve your needs in our sessions. This information is confidential and for use in our coaching relationship only. Your information will not be shared or made public in any way. Please return the 1stpage back to me at least 24 hours prior to our session.
Print a copy of this form for your file, fill it out, then scan & email copy to me at Ljsharedwisdomcanada@gmail.com or take a picture and text to 604-885-8282
|Name (first & last)|
|Phone Number (home or cell, please specify)|
|Date of Birth & location (town/city)|
|Time of birth (if known)|
|Spouse’s Name (if applicable)|
|Names and Ages of Children (if applicable)|
|Are you currently on medications or seeking therapy for any reason? Please acknowledge without details.|
Changes and Cancellations…
I respect your time and anticipate the same from you. It is important to be on time for our sessions as scheduled, having said this I also know that life can get in the way at times. In the event that you need to change a scheduled session, please give as much notice as possible. Be prepared to provide an alternative time/date for the reschedule. If it’s me who needs to reschedule I will do the same. Our sessions will start and finish on time unless we both agree to shorten or extend.
I am available for you should you get “stuck” or are trying to process an issue. Ask yourself the question “can this wait until the next session?” if the answer is yes, email me to give me the heads up so we can start with your issue. If not, please e-mail me immediately and I will contact you within 24 hours to discuss. Please note: additional fee is set at $150.00/hr with a minimum of 15 min
Trust is essential! I value your trust and promise that everything you share with me will remain in complete confidence. I do reserve the right to act if I feel for your safety or those around you are in jeopardy. In the case that I deem that it’s in your best interest to share your information with others, I will ask for your permission prior to sharing.
Referrals & Testimonials
I love referrals and testimonials! With the personal nature of coaching, being referred is one of the greatest compliments I could receive from you. If you refer someone and they enter into a coaching agreement, you will receive a 60-minute coaching session for free. Testimonials make a huge difference and they are essential to my business. I am truly grateful for your words and your permission to use them where appropriate.
Our coaching agreement or contract can be terminated at any time. All actions and decisions are yours and you alone are responsible for the results of these choices. As your coach, I will encourage, motivate, guide and assist you in achieving your successes. The real work is yours, how far you go and how fast you get there is up to you. Following our Get Me Started session, and upon agreement to move forward, I do require fee payments on or before the 1stday of the month for monthly services and 24 hrs prior to receiving all other services.
Payable by cash (in person only) or by e-transfer to firstname.lastname@example.org, I used auto-deposit so passwords are not required and can be left blank at your end of this transaction. If you are required to add one use “abby” to complete your e-transfer. I am not accepting credit cards or charging taxes at this time, this may change in the future and I will email your receipt once payment has been verified.
I am excited to work with you! The world of possibilities is an amazing place to be and I can’t wait to assist you in realizing your dreams & desires from this world!
“What you do today is important because you are exchanging a day in your life for it.”