Client Intake Form - One Heart Coaching 

Hello! I am so happy you are here and am honored to support you on your relationship journey. All answers will be kept completely confidential and won't be shared with your partner. We aim to secure a safe and supportive environment as we work together for hope, help and healing. Please answer what you can and we will review this together when we meet.
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Email *
First and Last Name *
Preferred pronouns
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Phone Number *
Address *
Preferred Method of Contact *
Emergency Contact (Name/Phone/Relationship to you)
Partner or Spouse Name *
Relationship Status *
How long have you been together? *
Children's Names and Ages (with current partner)
Children's Names and Ages (with previous partner)
Children's Names and Ages (partner came into relationship with)
Job Title, Profession, and/or Place of Employment *
Why are you seeking services? *
How did you find out about our services? *
Have you had any past experience with coaching or counseling, individually or together? If so, please describe. *
What relationship poisons do you currently express in your relationship? (check all that apply) *
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What relationship poisons does your partner currently express in your relationship? (check all that apply) *
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What are your favorite parts of your relationship?
What do you want more of in your relationship? *
What gets in the way of having this? *
What do you want less of in your relationship? *
What was the relationship of your parents like?
Briefly describe any major past relationships and why they ended.
On a scale of 1-5 how fulfilled do you feel in this life area: WORK
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On a scale of 1-5 how fulfilled do you feel in this life area: FINANCES
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On a scale of 1-5 how fulfilled do you feel in this life area: SECURITY
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On a scale of 1-5 how fulfilled do you feel in this life area: PURPOSE
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On a scale of 1-5 how fulfilled do you feel in this life area: GROWTH
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On a scale of 1-5 how fulfilled do you feel in this life area: FEELING LIKE A PRIORITY TO YOUR PARTNER
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On a scale of 1-5 how fulfilled do you feel in this life area: BEING ACCEPTED AND ENCOURAGED BY YOUR PARTNER
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On a scale of 1-5 how fulfilled do you feel in this life area: SEXUALITY
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On a scale of 1-5 how fulfilled do you feel in this life area: ADVENTURE
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On a scale of 1-5 how fulfilled do you feel in this life area: SOCIAL CONNECTIONS OUTSIDE YOUR RELATIONSHIP
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On a scale of 1-5 how fulfilled do you feel in this life area: HEALTH
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Do you or your family members have any history with mental illness? If so, please describe.
Are you currently on any medications or supplements for your mental health? If so, please list them and for what they are prescribed.
CANCELLATION POLICY:

Please provide at least a 24-hour notice if you need to cancel/reschedule. If you cancel/reschedule less than 24 hours before your appointment, you will be charged $35 per hour. If you cancel an appointment without contacting us at least 6 hours beforehand, you will be charged the full session fee. This time slot was not available to be filled by another client, and preparations and scheduling considerations were made based on your session. Thanks very much for honoring this.

Please note below if you agree to this.
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CLIENT AGREEMENTS

This outlines our commitment to you, our valued client, as well as our expectations of you. Please read and sign to acknowledge your agreement. Thanks so much.

We celebrate and deeply honor your commitment to grow, healing, and transformation. When we say YES to the life and relationships we really want, amazing things start to happen.

Our sessions are a judgment-free zone, and we will hear you with open hearts and minds and will keep everything shared in total confidentiality (unless required by law to report it).

Please let us know, at the beginning of the session, if you need to leave right at the designated amount of time we have set.

If scheduling allows, you may have the option of extending your session. In these cases, you will be charged for the actual total length of the session. If you will be charged for the additional time, you will first be given the opportunity to decide to extend the session or not.

You agree to assume and accept full responsibility for any and all risks associated with utilizing the techniques presented to you. You understand that we accept no responsibility or liability whatsoever for the use or misuse of the information presented or any techniques, processes, suggestions and activities that occur within or beyond a session.

Please have your payment with you, as it is required at the time of service. Payment can be made as cash, credit card, or check. 

We may have clients scheduled directly before you. If you are visiting our office, please let yourselves in and make yourselves at home in the waiting room. We will be out to greet you.

If we are meeting on Zoom, please enter the electronic waiting room, and I will begin the meeting as quickly as possible.

Coaching works like so many other things in life –the more you put into it, the more you get out of it. We invite you to open fully to all the new possibilities available to you, to stay present with the process, to be willing to change and grow and see things differently, to ask for whatever you need, to share your most honest thoughts and feelings, and to put into practice what we explore together.

It can also be helpful to come to each session with clear goals. We know your time is precious, and we want to make the absolute most of our moments together and to serve and support you as best as possible. This will allow you to receive the maximum benefits.

We truly look forward to the journey ahead and supporting you in every way we can!

We commit to supporting you in all the above ways.

PLEASE INITIAL BELOW TO ACKNOWLEDGE THAT YOU HAVE READ AND AGREE TO THE ABOVE.
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Thanks so much for sharing! If there is anything else you want us to know so that we can best serve you, you are warmly welcome to share here (optional). Can't wait to connect with you soon and support you in every way!
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