Client Intake Form
THIS IS A READ ONLY COPY- AT THE BOTTOM OF THIS PAGE YOU WILL FIND
A BUTTON FOR THE DIGITAL FORM FOR YOU TO FILL OUT.
Welcome. It is my privilege to work with you!
Thank you for carefully reading this document and then completing the digital copy as best you can.
Date: ________________
Your name ____________________________________________________________________________
Street Address _________________________________________________________
City ______________________________State______ Zip Code _________________
Cell Phone ___________________________ Age_________ Male/Female
Email ___________________________ Referral from _____________________________
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PERSONAL INVENTORY
What two areas of life are causing you the most pain and/or stress?
1.__________________________________________. 2.______________________________________________________________
How long have you been experiencing these difficulties?
1.____________________________ 2.____________________________________
For each difficulty, please rate from 1-10 how much the pain/stress affects your daily life.
1.___________ 2._____________
Please rate from 1-10: Quality of Life______ Overall Happiness_______ Physical Health_______
Spiritual Connection______ Feelings of Self Worth______ Amount of Stress________
Relationship Status ________________
Spouse’s name (if applicable) ____________________________________________________________
Children’s names & ages _______________________________________________________________________________
Occupation ___________________________________ For How Long? ___________
Any Additional Information about you ______________________________________________________
HISTORY
Have you ever received coaching/counseling for any reason? Yes ___ No ___
When? _______________ For How Long? _____________
For What Reason ________________________________________________
What worked well for you and what didn’t work well? _________________________________________________________________________________________________________________________
Have you been diagnosed with any chronic illness/conditions/disorders?__________________________
Please share any major recent life changes________________________________________________________
Are you dealing with any past or current addictions? Please explain ______________________________
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GOAL SETTING WORKSHEET
Please describe your reasons for seeking coaching, and why specifically at this time?
_______________________________________________________________________________________________________________________
What 3 specific personal goals would you like to accomplish while working with me?
GOAL #1_____________________________________________________________________________
This goal is important to me because: ________________________________________________________________________________________________________________________
Some barriers in my life that might get in my way of achieving this goal are:
__________________________________________________________________________________________________________________________
I know I will have reached my goal when...(I feel this….act like this…or believe this..)
______________________________________________________________________________________________________________________
GOAL #2 _________________________________________________________________________
This goal is important to me because: ________________________________________________________________________________________________________________________
Some barriers in my life that might get in my way of achieving this goal are:
___________________________________________________________________________________________________________________
I know I will have reached my goal when...(I feel this….act like this…or believe this..)
_________________________________________________________________________________________________________________________
GOAL #3 _____________________________________________________________________________
This goal is important to me because: ________________________________________________________________________________________________________________________
Some barriers in my life that might get in my way of achieving this goal are:
________________________________________________________________________________________________________________________
I know I will have reached my goal when...(I feel this….act like this…or believe this..)
_______________________________________________________________________________________________________________________
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CLIENT POLICIES & PROCEDURES
Welcome! So happy you’re here and are ready to find more peace and joy in your life. I look forward to working together. There are a few guidelines I would like to share that will allow us to best work as a team. If you have further questions, please call me.
FEE
Clients pay me prior to their session unless prior arrangements have been made. Payment may be made by venmo (@jennythueson)
$123 for a 60-minute session
PROCEDURE
My clients call/arrive on time.
Come prepared with what you want to work on and be ready to be coached. The agenda each time is client generated and coach supported.
SCHEDULING
Our financial agreement includes those appts. you have made. The day and time for the next session may be scheduled at the close of a coaching session or series of sessions.
CHANGES
I understand that things come up that we are not able to control. My clients give me 24- hour notice if they choose to cancel or reschedule our appt. A missed call or visit is forfeited, and you will be charged for the full amount of that session. I will make reasonable effort to reschedule sessions that are cancelled in a timely manner.
EXTRA TIME
You may text me between appointments if you need immediate coaching and I will determine if I am available. I would love to help if I can! These calls will be prorated according to the amount of time on the phone call.
You may also text me to share updates or if you have quick questions, I can easily help you with ,through text- at no charge.
CONCERNS
I want to do all I can to support you through this process. If I ever say or do something that upsets you or doesn’t feel right, please be willing to share this with me. It is imperative to your growth to have honest and open communication.
YOUR PART
It is necessary for you, as the client, to apply yourself in between visits to implement the coaching that is given in order to achieve the success you are desiring. You have hired a coach at this time to do things, and to help change self-defeating beliefs that are different than you ever have before. You will be given assignments that will help accelerate your learning. Choosing to be “all in” with these assignments will lead you towards the healing and success you are seeking!
MINORS
I am happy to coach children 13 and older, with the agreement of the child and the parents that there may be times when I request that the parents come to the coaching session in order to learn how they can best help their child succeed.
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COACHING AGREEMENT & INFORMED CONSENT
Welcome to Heart, Mind & Soul Holistic Healing with Jenny, a professional coaching practice. This document and its attachments constitute a contract between us (the “agreement”). You should read it carefully and raise any questions you may have before you sign it.
Services:
The services provided by Jenny Thueson include Coaching (phone, face to face, or zoom) on topics decided jointly with you, The Client. The purpose of coaching is to develop and implement strategies to help you reach personally identified goals of enhanced performance and personal life satisfaction. Coaching may address specific relationship concerns, life balance, job performance and satisfaction, spirituality, or general conditions in The Client's life.
If, at any time, you, The Client, feel that your needs are not being met or you are not getting what you want out of the coaching, please tell me, so we can discuss your needs and adjust your coaching program, as needed.
Life coaching is a powerful relationship which assists people to design their future selves and
to see more clearly their present and future, rather than staying in the past. Though we may look at experiences and false beliefs from the past and how they have affected you, our goal is to focus on the present and future.
As a coach, my responsibility is to assist you to
1. Help you to identify your past roadblocks to your desired outcomes
2. Support you in deciding which changes you would like to make
3. To develop a personal “action plan” in order to make those changes
4. To develop strategies to maintain the changes you have made
5. Educate you about the power and principles of honesty, responsibility and humility, which will create a stable place of healing and motivation for better. I will support, encourage, teach and help you stay on track toward your goals.
Your success will depend on your willingness to define and take risks and try new approaches. You can expect me to be honest and direct asking straightforward questions and using challenging techniques to help you move forward. It is an exciting process! And, like many worthwhile endeavors, coaching can involve feelings of distress and frustration that accompanies the process of change. The goal is to identify and work through those fears in order to move towards your personal goals.
Payment Procedure:
This agreement between Jenny Thueson (Coach) and the above-named client will begin on_______________________. The fee for a 60 minute session will be $123, payable in advance. Twenty-four (24) hours advance cancellation notice is required for all appointments in order to avoid being charged for the time that has been set-aside for you.
The Coach is paid in advance of each series of coaching calls or in person sessions. The first coaching appointment will begin after I receive this signed agreement and the first payment. You may pay by venmo.
Your signature below indicates that you have read the information in this document, Coaching Agreement & Informed Consent as well as Client Policies & Procedures and agree to abide by its terms during our professional coaching relationship.
Client _________________________________________ Date___________________________
Parent (if client is younger than 18) ________________________________________________________
Coach_________________________________________ Date___________________________