1-1 Coaching All journeys begin with the very first step. New Client Details & Coaching Agreement Personal Details Name * First Name Last Name Date of Birth * Email * Phone Number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Marital Status Occupation * Information Gathering Thank you for choosing to work with me to make some powerful and insightful changes in your life! To begin the process please take a few moments to answer the following questions and read the coaching agreement below. What are your expectations of the session? And how the session will be structured? * Please give a brief outline of issue: * How is this issue currently affecting your life? * Is there anything about your situation that would be helpful for me to know? * Do you believe it's possible to resolve your issues? * Yes No Maybe Brief Health History Please note any information you provide is confidential and will not be shared. Have you ever suffered a head injury that resulted in loss of consciousness or brain trauma? Yes No Have you received in-patient psychiatric treatment? If so, what, where and for how long? Have you experienced fits or Epilepsy in the past? If yes, when was your last episode? To help me assess your suitability for NLP Coaching or IEMT, please tell me if you have any medical or mental health issues that you have not yet mentioned on this form. If so, please list them here: List any prescribed or over the counter medication you are taking: Approximate alcohol intake per week (in bottles/glasses): Tell me a bit more about you What do you hope to achieve from working together and what would be a great result for you? * What do you believe might be preventing you from moving forward right now? * What will be different once you have changed? * How will this change affect family and friends? * What are your hobbies or interests? * What has been your best accomplishment to date, or what are you most proud of in your life? * Coaching Agreement & Expectations What is NLP Coaching? There are many definitions of coaching. For me it’s about helping you get unstuck by working out what is getting in your way, so you can move forward and live to your full potential. Coaching is a powerful conversation that inspires you to create that life you love. Many coaches are great at goal setting, action plans, inspiring and supporting but don’t have the skill set to deal with ‘why’ people get in their own way, and what do to change that. This is a key distinction with the work of NLP (Neuro Linguistic Programming). In my work I use a combination of NLP, hypnotherapy and coaching to help my clients get unstuck and make great change in their lives. What is IEMT? Integral Eye Movement Therapy (IEMT) is a rapid change therapeutic model that helps clients resolve past traumas, difficult memories, negative and unwanted emotions, and undesired identity traits. IEMT is a developing model, not suitable for everyone, however when used appropriately it has been found to be a very effective remedial tool for emotional change. The process largely involves observing and influencing eye movements enabling us to tap into the neural pathways that store our most profound emotions and experiences. The work of IEMT is largely content free which means you will not be required to speak about your past or current struggle to have your issues rapidly and effectively resolved. Together we will discuss and determine which is the most appropriate approach to help you resolve your issue. Responsibility My job as a coach is to support and empower you to attain the results you desire. Your job as a client is to show up on time and be ready to make change. It’s also important to follow through on any commitments you make during our time together, should we set any tasks to complete in between coaching sessions. Payment Details My standard coaching fee is $290 for an initial 90 min consult and $245 per hour thereafter. There is the option for a package of 4 coaching sessions for $840. Payment terms are same day and payable as direct deposit or by cash. Cancellation If you need to change or cancel an appointment, please provide 48 hours notice so I may fill this session to help another client. Should you need to reschedule, please email me. Confidentiality Our work is completely confidential and anything you say will say ‘within the room’. I aim to work with my clients with the upmost care and integrity. The only reason to disclose any personal information would be in the rare circumstance where this was required by law or where disclosing information is necessary to prevent a serious crime or serious harm to other people. Online Sessions By completing this form, you are agreeing that you are happy to use a third-party software package (Zoom) to participate in online coaching sessions. Emergency Contact * So that we can contact someone close to you in the case of an emergency please provide the following contact details: First Name Last Name Emergency Contact Phone Number * Coaching Agreement * I have read and agree to the information above. Please use initials to represent your signature: * Date * DD/MM/YYYY Woo hoo, all done! Let's get started! Thank you for take the time to complete this form.I look forward to speaking with you very soon!
