Pre Session Questionnaire
This form has two parts. Below you can see the first part that includes terms and conditions of our work together as well as questions that focus on your overall emotional health. The second section focuses on you personally and will help me know a little bit more about you and your personality. All answers are of course confidential. If there is a question you'd like to answer later you are welcome to type pass or select "other".
Thank you for getting through these first steps.
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Terms of Agreement and Waiver
In consideration of the services of, Emotional Health Coaching with Diana Deaver ("The Company"), a South Carolina Corporation,  I, an adult visitor, acknowledge and agree to the following terms and conditions:

COMPANY SERVICES.  Upon execution of this agreement, electronically, verbally, written or otherwise, the company agrees to render Services related to emotional health education, workshops, consulting, coaching, and personal goal achievement (The Emotional Health Sessions- "the sessions"). The terms of this agreement shall be binding for any further goods and services supplied by company to client. Parties agreed that the sessions are in the nature of self-analysis, life coaching and education.  All information discussed for the purposes of emotional health recovery will be provided to the client through session notes unless the client prefers not to receive session notes. The emotional health coach will instruct in various self-assessment exercises, may utilize discussion and other emotional healing techniques to facilitate the client's own transformation of habits and behavior patterns and achieve effective and lasting results. The scope of services rendered by the company pursuant to this contract will be solely limited to those contained therein and provided for on company's website (www.EmotionalHealthCoaching.com).

COMPENSATION: Client agrees to compensate company according to the payment schedule set forth on company's website, or via email, or payment schedule and the payment plan selected by the client ("the fee") or otherwise noted in this agreement. Company shall charge a 5% late penalty to all balances that are not paid in a timely manner by client.

REFUNDS: Upon execution of this agreement, client shall be responsible for the full extent of the fee. If client cancels attendance of the sessions for any reason whatsoever, the client will receive no refund.  In the event that client is in default of payment or otherwise in default of this agreement, all payments due there under shall be immediately due and payable. Company shall be allowed to immediately collect all sums from clients and terminate providing further services to client. In the event that client is in default of payments to company, client will be barred from using any of company's services.

NO RESALE OF SERVICES OR MATERIALS ARE PERMITTED:  client agrees to not reproduce, duplicate, copy, sell, trade, resell or exploit for any commercial purposes, any portion of the sessions including course materials and audio recordings.

NO TRANSFER OF INTELLECTUAL PROPERTY: Company's copyright original material shall be provided to the client for his or her individual use only and a single user license. Client shall not be authorized to use any of the company's intellectual property for clients business purposes. Client will not be authorized to share, copy, distribute, or otherwise disseminate any materials received from the company electronically other words without the prior written consent of the company.

GENERAL RELEASE AND LIMITATION OF LIABILITY: By using company services and participating in the sessions, the client releases company, its officers, employers, director, and related entities from any and all damages that may result from anything and everything. Client accepts any and all risks, foreseeable or not foreseeable, known or unknown, arising from such transactions and acknowledges that client understands that adverse effects of emotional health related exercises could occur in the future. Side effects and complications of emotional health life coaching can be defined as unexpected feelings, thoughts and behavior after or during a session that are in apparent conflict with the intended goals of the emotional life coaching.
Regardless of the previous paragraph, if company is found to be liable, all claims against company must be lodged with the entity having jurisdiction within 100 days of the date of the session in question or otherwise be forfeited forever. Client waves the right to bring suit for any cause of action under a statute of limitations longer than 100 days. Client agrees that use of company's services and products is at client's own risk.

DISCLAIMER OF GUARANTEE: Client accepts and agrees that he or she is 100% responsible for his or her progress and results from the sessions. Company makes no representations or guarantees verbally or in writing regarding performance of this agreement other than those specifically and numerated here and. Company and its Affiliates disclaim the implied warranties of titles, merchantability, and fitness for a particular purpose. Company makes no guarantee or warranty that the sessions will meet the client's requirements or that all clients will achieve the same results.

NOT SUBSTITUTE FOR PSYCHOLOGICAL OR MEDICAL TREATMENT: Life coaches and emotional health life coaches are not issued licenses by any state governmental agency to engage in their Professional Services. Life coaching is designed to act as an adjunct or complement to traditional therapies, or in effect, it's part of a holistic approach to self improvement and good health.

CLIENT RESPONSIBILITIES:  Please be aware that if the client has active suicidal intent, homicidal intent or a diagnosis of unstable mental health, the services are not recommended for the client. The information and techniques presented in the sessions are not intended to be a substitute for informed medical or psychiatric advice or care. The client should not use this information to diagnose or treat any health or mental health problems or illnesses without consulting a medical specialist of family doctor. Company does not provide medical, therapy, or Psychotherapy Services. Company is not responsible for any decisions made by client as a result of the services and any consequences thereof.
I have read, agree to the terms above and sign this agreement electronically by typing my name below. *
Today's Date:
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On average how much stress do you find yourself in every day?
stress free
stressed out
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Is most of your stress coming from internal or external sources?
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Do you do anything to relieve daily stress? Ex: yoga, meditation, relaxing walks, etc. Please share below.
How much physical effort do you engage in daily (gym, labor, jogging)?
Are you currently taking any legal prescribed drugs? If so, please list them here and share how often you are taking these drugs and for how long you have been taking them.
Are you currently taking any recreational drugs (including alcohol)? If so, please list them here and share how often you are taking these drugs and for how long you have been taking them.
Have you recently received any therapy or other mental emotional support from a professional? How long ago? Please share as much as you feel comfortable to about any help you have received in the past.
Do you currently have or recently had thoughts about hurting yourself in any way?
Do you currently have or recently had thoughts about hurting someone else in any way?
Which one of these do you find yourself challenged by?
Have you recently experienced or witnessed a traumatic event? (a traumatic event is an event that we experience as overwhelming and that we feel we are unable to process or handle) If so, please briefly share about it here.
Have you recently suffered a personal loss? (a job, a loved one, a health issue or possession/financial). If so, please briefly share about it here.
What do you most often struggle with in your life?
I most often crave
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