Client Portal & Coaching Forms Please fill out these forms to begin your life coaching journey! Step One: Intake Form Intake Form Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * DOB (Date of Birth) * Age * Gender * Ethnicity/Nationality * Relationship Status * Married Divorced Committed Relationship Single Occupation * Highest Level of Education * What 3 goals would you like to accomplish during our time together * Why do you want to achieve these 3 goals? * What has prevented you from achieving your goals in the past? * What major transitions have you experienced in the past 3 years? Examples might be relationship change, change in family or work, new role, a move, milestone birthday etc. * Disclosure * Beth Hall Life Coach collects certain personal information, including, your name, phone number, and postal address. Beth Hall Life Coach will NOT share this information with anyone else. This information will be solely used for life coaching purposes. Agree Client Signature * First Name Last Name Thank you! Step Two: Coaching Agreement Coaching Agreement Client: I will be punctual and well-prepared so we can make the most of our time together. I will consistently take the initiative in the coaching relationship with you. I am solely responsible for my own life and my own choices. I will follow through with my choices about what actions to take and what we work on together. I will complete the action steps agreed upon in our sessions. I will come to sessions prepared to focus without distractions. * Agree Coach: I will be punctual and well-prepared so we can make the most of our time together. I will be a trustworthy partner, honest and open with you. I will manage what you share with me with respect and discretion. I will come to our sessions prepared to focus without distractions. I am committed to believing in you, supporting you and encouraging you to reach your goals and live out your destiny. * Agree 1. Meeting Frequency: Meeting frequency is depended upon your coaching needs. We may meet once or twice a month, or every week. Meetings will take place via phone, digitally (Skye/Zoom) or face-to-face. Agree 2. 30 Day Review: We will review our working relationship after the first 4 coaching sessions. We will make the decision to continue working together or part ways respectfully. If you desire to end the coaching relationship prior to the 30-day review, a 48 hour notice is required. I can respectfully end the working relationship as well with 48 hours’ notice. Prior payment is non-refundable. * Agree 3. Action Steps: In each session we will agree upon action steps to be taken. These will always be reviewed at the start of the next session. Agree 4. Schedule: We will make every effort to hold rescheduling to a minimum. If you cannot make a scheduled meeting, you need to let me know with as much notice as possible- 24 hours. I respectfully promise to do the same. Client no-shows and cancellations, without any rescheduling, will incur the cost of a full session. Emergency situations will be considered. Agree 5. Payment: Payment installments are due at time of service. Frequent rescheduling due to non-payment may result in the coaching relationship ending. Credit, or debit payments, or business checks are accepted. No cash or checks. All payments are non-refundable. Agree Client Signature * First Name Last Name $$$ Price agreed upon during consultation * Date * MM DD YYYY Thank you! Step Three: Confidentiality Agreement Confidentiality Agreement The conversations we have in our coaching sessions are confidential and will be protected as such. Information will be shared outside of our sessions ONLY with your written approval (a signed ROI-Release of Information) and agreement. * Agree The following are examples where I am obligated by law to break our confidentiality without your permission or consent. * • It is assessed during our sessions that elder abuse or child abuse is occurring. • If you express harm to someone else with the intent of acting. • If there are legal issues involved where I might be contacted for information. • If you express thoughts of self-harm or suicide. I will make every effort to keep you from endangering your life. In some cases, this may involve calling your emergency contact or the police. Agree Client Signature * First Name Last Name Date * MM DD YYYY Thank you! Step Four: Statement of Intent Statement of Intent All coaching services delivered by Beth Hall are meant to challenge, support, and inspire you mentally, emotionally, and physically. It is important to note that coaching is not counseling. If you feel stressed to the point that you need to seek out professional counseling than I encourage you to do so. Life coaching may enhance your counseling if you are already connected with a mental health professional. Life coaching is about providing support and accountability. Life coaching is directed at the future, creating action goals and living your destiny. Life coaching is a partnership. * Agree Please read the list below and sign should you agree with each statement and wish to continue: 1. I understand the coaching services I receive from Beth Hall are not a substitute for mental health care, counseling, psychotherapy, or psychiatry. 2. I understand my coach, Beth Hall, will maintain confidentiality of our communication and session discussions. Confidentiality can change if someone is at harm to themselves or someone else, if there is elder abuse or child abuse or legal matters become apparent. 3. I understand that I am responsible for my own well-being and choices during coaching sessions. 4. I understand that all ideas, comments, or suggestions offered by my coach, Beth Hall, are solely for the purpose of supporting me in achieving the goals I have set forth for myself. Agree I hereby release, waive, absolve and forever discharge Beth Hall from claim, suit action, demand or right to compensation for damages that I may claim have resulted out of actions, omissions or commission taken by myself, or Beth Hall, as a result of the advice given in the professional coaching relationship. I further declare and represent that no promise, inducement, or agreement herein expressed has been made to me to enter into this release. The release made pursuant to the paragraph shall bind my heirs, executors, personal representatives, successors, and agents. I have read the statement above and understand and agree with the points contained therein: * Agree Client Signature * First Name Last Name Date * MM DD YYYY Thank you!
