Intake Consent Form

Disclosure Statement

Consciously Connected consultations and coaching sessions are for the purposes of education, support, and guidance on mental health and life stressors. Coaching can include the practice of Brainspotting, to assist in working through struck stress cycles and emotions held in the brain and body. Due to clinical licensure restrictions and ethical practices, consultation and coaching will NOT include clinical-level therapeutic interventions. If I determine that your needs are more aligned with this route, I can provide you with referrals to support you in this way while we work within the consultation and coaching guidelines. In consultation or coaching sessions you can expect to identify barriers to healthy functioning, problem-solve mental health or perpetual life stressors, utilize Brainspotting to process distress and work toward regulation, and be provided with psycho-educational material to increase awareness around your well-being.

Virtual office

Consciously Connected currently operates as a virtual business only. My connection to you will be strictly virtual, with availability on video calls, emails, and/or phone calls when necessary.

Fees

My hourly fee for consultation and coaching sessions is $160. Payment is expected prior to each session in order to secure your appointment spot. Cancellations with less than 24 hours notice, will result in a fee of 50% of the service fee.

Mandated Reporting

Despite the fact that I am not operating from my clinical licensure, I have an inextricable role as a mandated reporter. This means that if you disclose any instances of child abuse, child endangerment, child neglect, suicidal or homicidal plans or intention, or abuse or neglect to the elderly or the disabled I am required to report these disclosures. Please let me know if you have any questions or concerns about this. 


By submitting this form you are consenting to the terms listed above.

Email *
Name *
Phone number
Date of birth *
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Address *

Please list the goals you have for engaging in coaching or consultation at this time: 

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Please list the top 3 emotional or life stressors you are experiencing: 

Please list 3 strengths you consider yourself to have: 

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Is there anything else you would like me to know? 

A copy of your responses will be emailed to the address you provided.
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