New Client Form | Dr. Daryl Appleton
Name *
Address *
Phone number *
Emergency Contact // Name // Number // Relationship *
Meeting Preference // CURRENT APPOINTMENTS ARE ALL VIRTUAL (as of 1/2022) *
Required
Current Goals
Current Obstacles
Referral Source *
I understand that coaching is confidential (unless disclosure of harm to self and/or others and abuse of minors/elderly is acknowledged) and does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association and that coaching is not to be used as a substitute for counseling, psychotherapy, psychoanalysis, mental health care, substance abuse treatment, or other professional advice by legal, medical or other qualified professionals and that it is my exclusive responsibility to seek such independent professional guidance as needed. If I am currently under the care of a mental health professional, it is recommended that I promptly inform the mental health care provider of the nature and extent of the coaching relationship agreed upon by the Client and the Coach. *
I further acknowledge that I may terminate or discontinue the coaching relationship at any time. *
I have read and understood the coaching relationship, confidentiality, and sharing of information with Dr. Daryl Appleton located on her website https://www.drdarylappleton.com/legal *
I agree that it is the my  responsibility to notify the Dr. Appleton's Office 24 hours in advance of the scheduled calls/meetings. We reserve the right to bill Client the full amount of session price for a no-show or meeting canceled less than 24 hours before and that the Dr. Appleton will attempt in good faith to reschedule the missed meeting. *
A copy of your responses will be emailed to the address you provided.
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