1 on 1 Intake Form - Life Story Hacking

1 on 1 Coaching

I’m so excited to start working with you on your journey through life. To make the most of our time together please fill out the intake form below, agree to our terms of service and then click the button to schedule your free 20-minute discovery call, where we can chat and make sure we are going to be a good fit. I’ll be happy to answer any questions you may have and we can go together from there.

First Name

Last Name

What do you preferred to be called?

Phone Number

I do sessions in person (in Connecticut) or via Zoom. Which do you prefer?

In Person (In Connecticut) Zoom

Why are you looking for a coach?

If I could grant you three wishes during our time together what would they be?

If you could create three experiences for yourself, what would they be?

Is there anything else you would like me to know?

Client and Coach acknowledge and agree

By checking this book you indicate full informed consent, acknowledgement of, and agreement with the information outlined herein.

Client and Coach acknowledge and agree that coaching is a partnership (defined as an alliance, not a legal business partnership) between the Coach and the Client. Coaching services are designed to facilitate the creation/development of personal, professional, or career goals and to develop and carry out a strategy/plan for achieving those goals. Coaching includes no guarantees or warranties, expressed or implied, about any results to be achieved.

Coaching is not therapy, counseling or advice giving and is not a substitute for psychotherapy, psychoanalysis, mental health care, substance abuse treatment, legal, medical or other professional services. Coaching does not prevent, cure, or treat any mental disorder or medical disease and it is the Client’s responsibility to seek such independent professional guidance as needed.

Responsibility:
Coach will maintain the ethics and standards of professional behavior established by the International Coach Federation (ICF). The ICF Code of Ethics is available here: https://coachfederation.org/code-of-ethics. Client is responsible for personal, physical, mental, and emotional well-being and is solely responsible for decisions, choices, actions, and results. Client agrees to inform Coach of past or current mental health or substance abuse conditions, including concurrent treatment with other professionals. Coach is not and will not be liable or responsible for any actions or inaction, or for any direct or indirect result of any coaching services provided.

Confidentiality and exceptions to confidentiality:
Coach will keep all information and records confidential, to the extent defined by the laws of the state/country in which Coach and Client reside. Coach will not disclose any information pertaining to the Client without the Client’s written consent. Coach will notify appropriate mental health professionals and/or authorities if Client represents a danger to self or others. Coach may be a mandated reporter of child and/or elder abuse. Coach may share topics with other coaching professionals for training, supervision, and mentoring for professional development purposes without divulging any identifying Client information. Coach and Client acknowledge that communications via text and email are not encrypted nor secure, and therefore may not be confidential.