Qualifying Assessment for Group Coaching Series (Spring 2024)
Thank you for expressing interest in our upcoming group coaching session! To ensure optimal alignment we request you to complete a Qualifying Assessment. This assessment helps us to create an impactful experience for all members of the group. All responses are strictly confidential and will be utilized solely to enhance your coaching experience. Once you complete the form you will be notified within 1 business day if you've been accepted to the upcoming cohort! If you have any questions feel free to contact me at Ley@InfinityNorie.com.
Email *
Name *
Address *
Phone Number *
Date of Birth *
Emergency Contact Name: *
Emergency Contact Number: *
Racial Identity *
Gender Identity: *
Preferred Pronouns:  *
Are you currently in therapy?  *
Current therapist contact info (if applicable)
Are you currently experiencing a mental health crisis (suicidal thoughts, hopelessness, desire to harm others)
What's your poison?  *
What encouraged your participation in this group?

Group Coaching Clause:

Participants in this mental health group coaching program acknowledge and understand that while group coaching can be beneficial for personal growth, emotional support, and skill-building, it is not a substitute for individual therapy or professional mental health treatment.

Participants are encouraged to seek individual therapy or counseling if they have specific mental health concerns, diagnoses, or require personalized treatment plans. Although you will be working with a licensed provider, if you are currently receiving therapy or counseling, it is essential to maintain those services and continue working with your licensed mental health provider.

By participating in this mental health group coaching program, all participants acknowledge that it is not a replacement for therapy, and they are encouraged to seek appropriate professional help if needed.

Please type your full name agreeing to these terms and conditions:


Privacy and Confidential Clause:

All participants in this mental health group coaching program are expected to uphold strict confidentiality and respect for one another's privacy. Information shared during group sessions, including personal experiences, thoughts, and emotions, is to remain strictly confidential within the group.

Participants are prohibited from disclosing, discussing, or sharing any identifying or sensitive information about fellow group members outside of the group setting. This includes refraining from mentioning names, personal stories, or any specific details that could lead to the identification of another group member.

Failure to maintain confidentiality and privacy may result in the exclusion of the participant from the group coaching program.

This confidentiality and privacy clause is essential to create a safe and trusting environment where participants can openly discuss their mental health concerns and experiences without fear of judgment or breach of privacy.

By participating in this mental health group coaching program, all participants acknowledge and agree to abide by this confidentiality and privacy clause.

Please type your full name agreeing to these terms and conditions:

I acknowledge that upon acceptance into the group, I will be required to pay a deposit of $120 which will cover my first two group sessions. In the event that I choose to continue after the initial two sessions, I will need to pay $60 per session for the following four sessions.
A copy of your responses will be emailed to the address you provided.
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