Intake — Sequential Balance

Intake Form

Name

First Name

Last Name

Phone

(###)

###

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Contact Method

Text

Phone

Other

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

How did you hear about us?

Why are you seeking coaching?

For what purpose? Focus area.

I have read the Confidentiality & Consent agreement below this intake form and agree to the terms.

Please read and confirm agreement to the Confidentiality, Coaching Scope, and Participation Agreements below.

I agree

Confidentiality & Consent

CONFIDENTIALITY:

All information collected and discussed is intended only for the purpose of your sessions and will not be shared with anyone except in the following cases:

Your healthcare provider(s) (in case of an emergency)
There is a risk of harm to you or others
Other professionals, agreed upon in advance, to collaborate with to realize your vision.

Your Coach promises to treat both you and your information with respect and the strictest confidence.

COACHING SCOPE:

Your Coach is not a psychotherapist, counsellor or mediator and therefore asks that you follow-up with the relevant specialist for concerns of this nature.

PARTICIPATION:

You are under no obligation to follow my direction should you feel the need to deviate from the plan at any point for any reasons. Our relationship is completely voluntary and you may withdraw from participation at any time before, during, or following a session.