Mindfulness Coaching Client Information Form
CECILIA DING               SELF-GROWTH COACH  and COUNSELOR                WWW.CECILIADING.COM

Please note this 8-week MBSR program is highly structured and thus will be very focused on psychoeducation and practicing.  This will not be much room for exploring personal goals outside the mindfulness area. If interested in more customized coaching, please sign on for Individual Coaching here.


*After you have finished the form, please use this link to schedule an appointment
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Basic Information
First and Last Name
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Date of Birth *
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Phone Number *
Email *
Current Address *
Emergency Contact
Education and Employment
Highest degree completed in school
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Have you practiced mindfulness/meditation or taking or mindfulness or meditation course before? If yes, please describe briefly what helped and what did not help.

Exploring who you are and your goals, you do not have to answer every question below; however you are encouraged to think deeply about your goals and assess your commitment in order to make this a productive experience: 


Why have you decided to take this course?

What are the primary short-term goals you wish to achieve by taking this course? *

What long term goals do you want to focus on through improving mindfulness. 

*

What are some of your current mindfulness practice or strengths?

What is the area of your life you want to improve mindfulness

What else do you feel I should know about you so that I can guide you in this program? 

Thank you for your time filling out the form,  please read the information on fee, confidentiality and agreement below and submit the form. I look forward to meeting you. 

Fees

The 8-week structured mindfulness coaching and guidance program is 1000 dollars, payable in 4 installments.  For group coaching, 6 minimum participants are required, each participant's fee is 200 in 1 payment. 

Appointment Cancellation Policy:  To maximize the benefit from the program, continuous 8 week commitment is highly recommended. In the event that you must cancel or reschedule a session, please inform Cecilia as soon as possible through email. No refund would be issued for missed session without twenty-four hour notice provided.

Payment: You can pay through paypal payment portal and also set up payment plan. 

Professional Ethics: I, Cecilia Ding, subscribe to the Code of Ethics for International Confederation of Coaching. 


Confidentiality: In recognition that confidentiality is an integral part of successful relationship, I maintain confidentiality with respect to every aspect of the coaching process.  *Once you have submitted this form, you will be sent an official coaching agreement form with detailed more information on confidentiality and scheduling.


 

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