Coaching Intake Form and Informed Consent
831.471.7195 (phone and text)
Questions without a red asterisk next to them are optional
Date of Birth
Prefer not to say
Enter best phone numbers to reach you along with a label stating what type of phone each number is. For example 555.555.1212 mobile (press enter for new line to enter multiple phone numbers)
Street Address 1
Street Address 2
State or Province
Zip or Postal Code
Employment and Health Insurance
Health Insurance Company
Primary Person for Insurance
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 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)
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.
By clicking this checkbox I acknowledge that I have read and accept the terms listed on this page
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