Intake & Consent Form
Before your first session with Karina Mirsky, MA, please fill out this form:
- Takes 3-4 MINUTES to complete
- Submit 48 HOURS before your 1ST appointment
*Please also whitelist:
First & Last Name - (feel free to add a nickname or the name you prefer to be addressed by)
Preferred Pronoun (optional)
Who were you referred by?
I am seeking to work with Karina PRIMARILY for:
Integrative Holistic Coaching (whatever is most needed)
Parts Work Therapy
Yoga Therapy: (pain management, meditation, breathwork, relaxation)
Couples Coaching (partner sessions)
Supervision for Yoga Teachers & Coaches
I seek support PRIMARILY for:
Managing Emotions (grief, anger, anxiety, depression)
Lifestyle & Stress (insomnia, burnout, overwhelm, fatigue)
Transforming Disempowering Beliefs or Behaviors
Self-Awareness, Self-Development, Personal Empowerment
Love & Relationship Issues
Physical Health Challenge (pain, injury, illness)
Are you currently being treated for or managing any significant physical or psychological health condition?
Are you taking any medications that might be useful for Karina to know about? (hormones, blood-pressure, antidepressants, sleeping pills, etc)
Is there anything else you would like Karina to know at this time? (optional)
What is your preferred method of payment?
Credit or Debit Card (through website)
Cash or check (local clients only)
PAYMENT POLICIES: By checking the boxes below you are confirming that you understand and consent to policies for payments
I understand that Karina is not a licensed LPC or LSW & can NOT bill insurance companies.
I understand the rates for a single session, discount packages & follow-up calls
If I have access to less than $30K/yr, I can request a sliding scale fee. This must be agreed to prior to scheduling.
For Tele-Coaching, payment is due 48 hours prior to my appointment.
For In-Person, payment is due at the end of the session.
There is a 48 hour cancellation policy. If there is a need to cancel within 48 hours, I will make a donation of at least 50% of the session fee to stay in good standing for rescheduling
COACHING RELATIONSHIP AGREEMENT: By checking the boxes below you agree to enter into a coaching relationship with Karina:
I understand that the best way to contact Karina is via email
I am committed to showing up for my scheduled appointments on time
I may request follow-up calls for emergency situations via email, and Karina will do her best to accommodate.
I understand that Karina is an international educator and may not be available some weeks or months during the year
I take responsibility for my own wellbeing and progress
I understand that Karina is committed to anti-discrimination & anti-racism and welcomes feedback on how to be a better ally to POC, LGBTQ+, and Differently Abled people
Send me a copy of my responses.
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