Coaching Intake Form Step 1 of 3 33% Client InformationName* First Last Date of Birth* MM DD YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Please provide the best number to reach youEmail* This field is hidden when viewing the formDate of submission MM slash DD slash YYYY Alternate ContactName* First Last Relationship*Phone* Terms and ConditionsCoaching Agreement*1. Coaching is not therapy, counseling, advice giving, mental healthcare, or treatment for substance abuse or any addictive behavior. The coach is not functioning as a licensed mental health professional, therapist or counselor, and coaching is not intended as a replacement for counseling, psychiatric interventions, treatment for mental illness, recovery from past abuse, professional medical advice, financial assistance, legal counsel, or other professional services. 2. Coaching is for people who are basically well adjusted, emotionally healthy, functioning fairly effectively, and wanting to make improvements in their lives. 3. Coaching can involve brainstorming, values clarification, the completion of written assignments, education, goal-setting, identifying plans of action, accountability, making requests, agreements to change behavior, examining lifestyles, and questioning. 4. The client is the sole decision-maker in the coaching process. Any and all actions or consequences resulting from the coaching sessions are the responsibility of the client. The client releases the coach of all liability pertaining to the services rendered in the coaching relationship. 5. The fee for coaching services is $150 per coaching session of 50 minutes each. I have read and agree to the Coaching AgreementConfidentiality of Services*Coaching is a confidential relationship and the coach agrees to keep all information strictly confidential, except in those situations where such confidentiality would violate the law. I agree with the Confidentiality of ServicesLate Cancellation/No Show*Please let us know at least 48 hours in advance if you can’t make it to your appointment. No shows or Cancelled visits within 24 hours will be billed for the full fee. I agree with the Late Cancellation/No Show FeeCredit Card on File Policy*We strive to provide great services at a very affordable price. In order for us to continue to provide high-quality services, we strictly follows a ‘Credit Card on File’ policy. The credit card on file can be used to pay for services. The credit card will also be charged in case the appointment is canceled within 24 hours of the scheduled appointment as well as for Missed Appointments & No Shows. Holistic Bonfire LLC does not store your credit card details. The card details are securely saved on Square, Inc., a third party payment services platform. I agree with the Credit Card on File PolicyThe Terms and Conditions have been electronically signed by:* First Last Signature*Electronic Signature Consent* I consent to signing this document electronically.