Client Intake Form - Intimacy & Relationship Coaching
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Email *
First & Last Name *
Date of Birth *
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Email *
Phone number
What are the three things you most want from our work together?
Are you currently in a relationship?
What are you most struggling with in life right now?
Do you have any reservations about working with a coach?
Provide some insights into aspects of your sexual history that you believe are pertinent to our work together.
What can I do to make you feel safe and supported?
What are top three things that you want to move through / release / transform in our time together?
Additional Comments, anything else you would like me to know.
Terms & Conditions

Participant understands Company (MARIIA KHRIACHTCHEVA / THE PINK LADY) and its subsidiaries, owners, principals, directors, executives, employees, staff, or agents are not lawyers, doctors, managers, therapists, business managers, registered dietitians, financial analysts, psychotherapists or accountants.

Participant understands their participation in this/these sessions will not treat or diagnose any disease, illness, or ailment and if they should experience any such issues they should see their registered physician or other practitioner as determined by their own judgment. Participant understands that the sessions are not a substitute for health care, medical or nutritional advice of any kind.

Participant understands and agrees that Participant is fully responsible for their mental well being during the live calls, and subsequently, including their dietary, mental and physical choices and decisions during the sessions. Participant agrees to seek medical advice as determined by their own judgment before starting this or any other program or discontinuing use of any medications as prescribed by their medical practitioner. Participant understands Participant is fully responsible for any and all adverse reactions, including but not limited to, emotional or physical reactions to the content in the class.

Participant understands that all suggestions offered by MARIIA KHRIACHTCHEVA are solely for the purpose of aiding Participant in achieving Participant’s defined goals. Participant has the ability to give their informed consent, and does hereby give such consent to MARIIA KHRIACHTCHEVA to assist in achieving such goals. Additionally, the services are offered on an “as is,” “where is,” and “where available” basis, with no warranty of any kind — whether express, implied, or statutory — including, but not limited to, warranties of title or the implied warranties of merchantability or fitness for a particular purpose. This does not affect those warranties which are incapable of exclusion, restriction, or modification under the laws applicable to this agreement.

Participant acknowledges that neither Company, its affiliates, nor any of their respective employees, agents, third parties, or licensors warrant that the services will be uninterrupted or error free; nor do they make any warranty as to the results that may be obtained from use of the services, or as to the timeliness, sequence, accuracy, reliability, completeness, or content of any information or service provided through the Program. Participant understands that the Participant does not offer any representations, warranties, or guarantees, verbally or in writing, regarding any results of any kind. Participant agrees that its results are dependent on various factors and in no way dependent on any information Company provides to Participant. Except as specifically provided in this agreement or where the law requires a different standard, you agree that Company is not responsible for any loss, property damage, or bodily injury, caused by use of the class. To the maximum extent permissible under applicable law, Company will not be responsible to Participant or any third party claims through Participant for any direct, indirect, special or consequential, economic or other damages arising in any way out use of the class.

Confidentiality
All information shared by the client during coaching sessions will be treated as strictly confidential. I will not disclose any personal or identifying information without the client’s explicit written consent, except where required by law or if there is an immediate risk of harm to the client or others. This confidentiality obligation applies to both verbal and written communications.  
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