Mental Health Coaching Consent & Intake Form

Informed Consent & Coaching Agreement

Our coaching relationship is built on mutual respect, honesty, and personal responsibility. Each coaching session is designed to create a supportive, safe, and confidential space where you can explore your goals, values, and personal growth. You are encouraged to take an active role in your own transformation.

Mental health coaching is a non-clinical, collaborative process focused on helping you clarify values, achieve goals, improve habits, and strengthen your sense of well-being. It is not therapy, counseling, or a substitute for licensed mental health care. I do not diagnose or treat mental health conditions. If clinical support becomes necessary, I will recommend appropriate referrals.

Confidentiality

Your privacy is important. While I am not engaging as a licensed mental health professional and therefore not bound by HIPAA, I treat your information with care and discretion. All communication will be kept confidential, except in the following cases:

- You express intent to harm yourself or others.
- I have reason to believe abuse or neglect of a child, elderly, or vulnerable adult has occurred or may occur.
- I am required to comply with a lawful court order or subpoena.
- You give written consent for me to communicate with another person or professional.

Coaching Sessions & Fees

Coaching sessions are available virtually. The standard session lengths and rates are:
- 50 minutes: $150

- 90 minutes: $210 (available on request)
Payment is due at the time of scheduling.

Cancellation Policy

Cancellations made with less than 24 hours' notice, or missed sessions without notice will not be refundable.

Communication Policy

You may contact me by email or phone. I make every effort to return messages within 24 business hours. Please note that I am not available for emergency support. If you are in crisis, please contact a crisis line, 911, or your local emergency services.

Coaching Relationship

This coaching relationship is voluntary and can be ended at any time by either party. If your needs fall outside the scope of coaching, I may recommend a referral to another professional. Our interactions will remain professional at all times.

Privacy and Record-Keeping

Session notes, if kept, are used solely for the purpose of supporting your progress and will not be shared unless required by law or with your written consent. You may request copies of your notes at any time.

Consent to Coaching and Cancellation Policy

By signing below, you acknowledge that:

- You understand the distinction between coaching and therapy.
- You agree to the terms above, including confidentiality, fees, Cancellation policy, and communication boundaries.
- You voluntarily consent to participate in mental health coaching sessions.

Full Name *

Signature Acknowledging Cancellation & No Show Policy *

Clear

Today's Date *

Coaching Intake Questionnaire

Client Information

First Name *

Last Name *

Date of birth *

Street Address *

City *

State *

Postal code *

Phone *

Phone Type

Email *

Is it okay to leave a voicemeail or email you? *

Yes

No

If no please explain:

Emergency Contact *

Emergency Contact Phone *

Current Concerns and Goals

What brings you to coaching at this time? *

Have you worked with a coach, mentor, or guide before? *

Yes

No

If yes, what was helpful (or unhelpful) about that experience?

What would you like to focus on in our work together? *

What do you hope will be different in your life as a result of coaching? *

What are your top personal values or priorities right now? *

What typically gets in your way when trying to make changes? *

Lifestyle & Well-being

How would you describe your energy and mood lately? *

Sleep habits: Average hours of sleep: *

Movement or exercise: What kind and how often?

Nutrition and hydration: Are you satisfied with your current habits? *

Yes

No

Stress levels: On a scale of 1–10, how would you rate your current stress? *

Do you currently practice any mindfulness, faith-based, or grounding habits? *

Personal Background

Who currently supports you (friends, family, community)? *

Do you have children? *

Yes

No

If yes, please list ages

What is your current occupation? *

Are you fulfilled in your work? *

Yes

No

Are there any major life transitions you're currently navigating? *

Do you have any history of working with licensed mental health or medical professionals? *

Is there anything else you'd like me to know before we begin?

Coaching Preferences

Preferred session length: *

50 min $150

90 min $210

How often would you like to meet? *

Weekly

Biweekly

Monthly

As Needed

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Privacy Policy | Terms of Service

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