Robin Fett
Coaching Intake Form and Informed Consent
831.471.7195 (phone and text) rfett@siliconvalleytherapy.co
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Demographics
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Full Name *
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Date of Birth *
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Employment and Health Insurance
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Emergency Contact
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Relationship *
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Services and Fees
HOW TO PAY FEES
1. Cash or Check (payable to Silicon Valley Therapy)
2. Google Pay (via your provider's email address, debit cards preferred)
3. Credit card via invoice

COACHING*
Coaching for individuals, couples, families, or groups. Location for session is one of Silicon Valley Therapy's offices, an alternate location, video, or phone.

$150 - Individual Coaching (45-55 minute session)
$75 - Individual Coaching (20-30 minutes session)
$150 - Couples or Family Coaching (45-55 minute session)
$75 - Group Coaching (65-75 minute session)

ADMINISTRATION
Time outside of session may be necessary to prepare reports, complete assessments, write contracts, or other administrative support for the coaching process. Any fees will be discussed up front and agreed upon before incurring fee.

$150 - Administrative Time (45-55 minutes)
$75 - Administrative Time (20-30 minutes)

* Coaching services and fees may be covered under your insurance plan. Please check with your insurance provider for benefits and reporting requirements for reimbursements.
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