Confidential Client Information
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Email *
Center for Thriving Relationships • Joy Potential
4307 S Leonard Springs Rd
Bloomington, IN 47403
The Eartheart Institue, Eartheart LLC
Name: *
Date of Birth:
*Required* for Insurance Clients
*Required* for Insurance Clients
(Home)      (Work)       (Cell)
Email address:
Best way of contact:
Email/Text Consent: *
Insurance: Please send a copy of the front and back of your card to us at or 812-223-7186
Insurance Company and Insurance Policy Number:
Please include the name and date of birth of the policy holder if different as well as any relevant information from the back of the card
Preferred Billing Method:
Payment is due at the time of service or can be made by a card on file.
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Emergency Contact:
Occupation & Workplace:
How did you find out about our services?
Spouse/Significant Other:
Relationship status:
(dating, engaged, domestic partnership, married, etc.)
How long have you and your beloved been together?
Years together?     Years married?
Children's Names and Ages:
Children with your current beloved? Children with previous partner(s)? Children your beloved had with previous partners(s)?
Why are you seeking services?
Have you had any past experience with counseling or coaching, individually or together?
If so, please describe.
What do you see as your biggest challenges in your relationship?
Regarding your CURRENT RELATIONSHIP: Which of these relationship poisons show up or have shown up in the past?
Simply select any of the behaviors (in your perspective) of you and your current partner.
PLEASE NOTE: **Past refers to this relationship that you are presently in; it simply means the behavior happened before, but is no longer occurring.
Do not consider any past relationships here.
Physical Violence
Verbal Aggression
Silent Treatment
What are your favorite parts of your relationship?
What do you want more of in your relationship?
What gets in the way of having this?
What do you want less of in your relationship?
What was the relationship of your parents like?
Briefly describe any past major relationships and why they ended.
On a scale of 1-10, how fulfilled do you feel in each of these areas of your life?
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Social connections outside your relationship
Clear selection
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Being accepted by your beloved
Clear selection
Encouragement and support from your beloved
Clear selection
Feeling like a priority to your beloved
Clear selection
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Do you or your family members have any history with mental illness?
If so, please describe.
Are you currently on any medications?
If so, please list them AND what they are prescribed for.
Special Interests/Requests
Is there anything you'd like for us to know about you so that we can best serve and support you?
Please confirm: *
Client Commitments and Financial Policy
This outlines our commitment to you, our valued client, as well as our expectations of you. Please read and sign to acknowledge your agreement. Thanks so much! We celebrate and deeply honor your commitment to growth, healing, and transformation. When we say YES to these things, to the life and relationships we really want, amazing things start to happen. Our sessions are a judgment-free zone, and we will hear you with open hearts and minds and will keep everything shared in total confidentiality (unless required by law to report it). You can find a complete copy of our Notice of Privacy Practices at which outlines your rights and our responsibilities under HIPAA. Your signature below confirms your consent to the release of personal information for billing purposes, such as insurance claims. Please let us know, at the beginning of the session, if you need to leave right after the designated amount of time we’ve set. You do have the option of allowing your session to extend past the scheduled amount of time. In these cases, you will be charged for the actual total time of the session. You agree to assume and accept full responsibility for any and all risks associated with utilizing the techniques presented to you. You understand that Eartheart LLC accepts no responsibility or liability whatsoever for the use or misuse of the information presented or any techniques, processes, suggestions and activities that occur within or beyond a session. Please have your payment with you, as it is required at the time of service. Payment can be made as cash, credit card, or check. CANCELLATION POLICY: Please provide at least 24 hours’ notice if you need to cancel. If you cancel less than 24 hours before your appointment, you will be charged $35 per hour. If you miss an appointment without contacting us at least six hours beforehand, you will be charged the full session fee. This time slot was not available to be filled by another client, and preparations and scheduling considerations were made based on your session. Thanks very much for honoring this. We may have clients scheduled directly before you. If you are coming in person, please let yourselves in and make yourselves at home in the waiting room. We will be out to greet you. FINAL LOVING NOTE: Coaching and counseling works like so many other things in life – the more you put into it, the more you get out of it. We invite you to open your mind and heart to all the new possibilities available to you, to stay present with the process, to be willing to change and grow and see things differently, to ask for whatever you need, to share your most honest thoughts and feelings, and to put into practice what we explore together. It can also be helpful to come to each session with clear goals. We know your time is precious, and we want to make the absolute most of our moments together and to serve and support you as best as possible. This will allow you to receive the maximum benefits. We truly look forward to the journey ahead and supporting you in every way we can!
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