Name
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First Name
Last Name
Preferred name/nickname
Pronouns
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They/them
She/her
He/him
Date of Birth
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MM
DD
YYYY
Phone
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Country
(###)
###
####
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
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Are you currently working with a therapist? If yes, for how long?
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Have you been diagnosed with mental or emotional instability by a mental health professional? If yes, what is your diagnosis? (While I don't adhere to a diagnosis-based approach to mental and emotional wellness, it's important for me to know your background in this area.)
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Are you currently taking any medications prescribed for mental or emotional support? If so, what?
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Have you experienced what you'd describe as an emotional crisis recently? If yes, please describe.
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Have you done this kind of coaching work before? If yes, with whom? If no, what makes now the right time?
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What is the a primary topic or concern you'd like to make sure we talk about?
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What are some things that hook or trigger you? (I'm not necessarily going to avoid these things, but want to be mindful of extra-sensitive spots.)
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If we're successful in our work together, what will be different -- for you, and also within your relationship?
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Is there anything else you think I should know? Don't be shy.
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By checking this box we acknowledge that we are embarking on transformational life coaching work, and that this work is not therapy. We recognize that we are not working with a licensed therapist, and that if we need support managing acute emotional distress, we will reach out to an appropriate mental health or crisis professional in our area. We acknowledge that if through the course of our work together either of us state a clear intention to kill ourselves or anyone else, Emily Ballard is legally bound to report this information to the proper authorities in our area. We acknowledge that this work is not intended to support acute emotional distress or ongoing management of mental health symptoms, and we release Emily Ballard from responsibility for the management of our mental and emotional health. We acknowledge that the nature of coaching and other support work is fluid, which in this case means the coach (Emily Ballard) and we (clients) may jointly agree to stray from the stated content of the package we have purchased if we feel this is most beneficial for our (client’s) well-being. We recognize that this does not equal breach of contract, but a mutually agreed upon shift in direction. Lastly, we recognize that we are agreeing to pay for the package we have signed up for in full. We understand that if we (clients) have entered into a payment plan with Emily Ballard, that we (clients) may be paying for services rendered *even after* those services are received. We (clients) acknowledge that we understand the stated payment arrangement with Emily Ballard, and we agree to the terms. We understand that all coaching packages purchased via Emily Ballard are non-refundable.
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Welcome to your standard, required legalese-y statement.
