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Resilient Mamas Coaching Form
Thank you for your interest in Resilient Mama Coaching Services! Please complete the following form. This information is kept completely confidential and assists me in tailoring services to your needs. You may choose not to answer any question. Once you have completed the form I will contact you within 1 week to schedule a session.
Name
Your answer
Phone Number
Your answer
E-mail Address (only to be used for communication to schedule sessions, your e-mail is kept private and not added to any list)
Your answer
How would you like to be contacted to schedule a session?
How did you hear about Resilient Mamas?
Your answer
What is your preferred meeting time? Please check all that apply.
How would you describe yourself? What are some of your strengths? Tell me anything about you that you feel would be helpful for me to know.
Please indicate if you are expecting or the age(s) of your child(ren).
Your answer
What do you hope to gain from coaching sessions?
Your answer
What areas are you interested in receiving support?
What describes you best?
What describes you best?
What describes you best?
Please describe your current employment status (full time, part time, on maternity leave, stay at home parent).
Your answer
What are some of your hobbies/interests?
Your answer
Fill in the blank. I feel I am yearning for more __________ in my life.
Your answer
How would you describe your learning style? Check all that apply.
Please type your name to acknowledge that you have read, understand, and agree to the disclaimer. Disclaimer: By participating in Resilient Mama Coaching Services I acknowledge that I am not receiving psychotherapy services and that coaching services are not intended to diagnose, treat, or cure any mental health conditions. I may be offered screening for mental health conditions and given referrals through this service but claim responsibility for securing my own mental health services if needed. I understand that outcomes of coaching services can not be guaranteed. I understand that any personal information shared with my coach is kept confidential with the exceptions of limits of confidentiality. I understand that if I make statements that inform my coach of known child or elder abuse, or that I am a risk to harm myself, another individual, or that I am at risk of being harmed by someone else that appropriate authorities and service agencies may have to be notified by my coach due to mandated reporting regulations. I acknowledge that you are participating voluntarily coaching services and that I am solely and personally responsible for my choices, actions and results, now and in the future. I accept full responsibility for the consequences of your use, or non-use, of any information provided on or through Resilient Mamas website, support group, and services and I agree to use my own judgment and due diligence before implementing any idea, suggestion or recommendation from services to my life.
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