COACHING PROGRAMS

Therapeutic & Intuitive Life Coaching For Those Ready To Do The Work To Take Control Over Their Life & Shaping Their Future

COACHING INTAKE FORM

I'm looking forward to getting to know you more

Coaching Client Intake Form

Please fill out the form below as detailed as possible so I can get a chance to get to know you and the areas you're looking to get help with. This will also ensure that we are a good fit to work together.

First name

Last name

Phone

Have You Received IFS Coaching Or IFS Therapy Before

Yes

As An Intuitive Life Coach & IFS Practitioner I May Include Intuitive Guidance And/Or IFS Life Skill Coaching Into The Session. How Do Yo Feel About That?

I'm open to IFS combined with intuitive and life skill coaching if applicable

I'd like to stick to traditional IFS sessions

I'm not sure, let's explore together

Please Share About Some Of The Areas In Your Life You Struggle Most With That You're Hoping To Address And/Or Explore With My Help

Are You Currently Receiving Any Other Form Of Therapy Or Coaching Through A Licensed Mental Health Professional (therapist, counselor, social worker etc)

Yes

If yes, what kind of therapy (ie. talk therapy, EMDR, Cognitive Behavior Therapy etc)

If you previously have been or currently are diagnosed with a "mental health condition", please let me know below about the diagnosis and how this is currently affecting you.

If you haven't been directly diagnosed with a mental health condition, but have experienced moderate or strong anxiety/depression/panic attacks or anything else, please describe below how this is usually affecting you

Anything Else You'd Like Me To Know About You? Any Questions Or Concerns You Have About The Sessions?

Terms & Conditions

Payment & Cancellation Policy:

All payments are non refundable. If cancellation is made through the system or by email to rootedinbetween@gmail.com at least 48hours prior to the scheduled session, the affected session may be transferred to a future date. Cancellations made less than 48hours prior to the scheduled session can not be transferred and no monies will be refunded.

Confidentiality Agreement

Rooted In Between respects the privacy of their clients and agrees to keep all personal information of the client and anything that is shared within the session in regards to the client private at all times and will not share it with any third party unless it is an emergency situation affecting the physical safety of the client or any member of Rooted In Between.

Disclaimer & Assumption Of Client Personal Responsibility

The client understands that Rooted In Between and its members and affiliates are not licensed mental health professionals. The services provided by Rooted In Between and its associates are not a replacement for medical advice by a professional or mental health treatment by a licensed professional.

Forms of self reflection, life coaching, or coaching such as but not limited to as the coaching from the Internal Family Systems modality may trigger the nervous system and/or may bring suppressed emotions to the surface and may temporarily cause, increase or worsen symptoms of already existing mental health conditions.

For their own benefit, and prior to starting coaching with Rooted In Between, the client may consult with a licensed mental health professional to determine the suitability of the program if the participant is currently working with a licensed mental health professional, or is currently or has been in the past diagnosed with any mental health condition or if there is any other concern.

At any time prior, during or at any time after coaching through Rooted In Between where the client experiences disruptions affecting their day to day life in conjunction or as a result of the work with Rooted In Between, it is their responsibility to discontinue the services, sessions, or practices recommended by Rooted In Between and if they deem necessary contact a licensed mental health professional for support. In an emergency, if the client may feel they are a danger to themselves or others, they shall contact their local emergency hotline for immediate support.

Liability Waiver

Rooted In Between and its members and affiliates, assume no liability for any damage, health or behavior related consequences to any person, animal, living being or property including but not limited to injury, sickness, accident, death or damage of any kind caused from the participation in or any direct relation of applying the skills learned in the program.

By checking this box acknowledge that I have read, understand and agree to the terms above

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