Name

MaleFemalePreferred Pronoun

Address

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Subject

DOB

Occupation

Referral Source (Name)

Have you previously received therapy or counseling? YesNo

Current Diagnosis, if any

Insurance Information

This office does not submit claims to insurance companies. You are responsible for your own payments.

Confidentiality

All communication between client and coach will be held in confidence unless written consent for release is obtained. But there are a few exceptions. There are some situations in which I am legally obligated to take action to protect others from harm. If the client threatens to harm himself/herself, I may be obligated to contact family members or others who can help provide protection.

WELLNESS/GRIEF AND LOSS COACHING SERVICES

Wellness/Grief and Loss coaching varies depending on the personalities of the participant, and the particular concerns you bring forward. There are many different tools I may use to address your concerns. Wellness/Grief and Loss coaching can have tremendous benefits; however, it often involves discussing unpleasant aspects of your Wellness/Grief and Loss you may experience uncomfortable feelings like sadness, guilt, anger, shame, frustration, loneliness, and helplessness. On the other hand, Wellness/Grief and Loss coaching has also been shown to lead to better relationship with yourself and others. The success of your wellness journey is ultimately up to you.

Office Policies & Procedures

Coaching workshops are 45-50 minutes, with scheduling. Payment is due at the beginning of each session. The fee for one workshop is $75.00. Other services, including telephone calls of more than 15 minutes, are charged at the same rate. You will be charged a $50 fee for all missed appointments unless you provide 24-hour advance notice.

If I am not available by phone, please text me (818) 646-6608. Your message will be returned within 24 hours. If you are experiencing a crisis and need immediate assistance, you should call 911.

have-read I have read the information regarding financial arrangements in the paragraph above. I understand that I am financially responsible for all charges incurred by me.

Your signature below indicates you have read and understand the information in this document and agree to abide by its terms.

Client’s Name
Date Signature

Mental Health Specialist/Grief and Loss Coach’s Name
Date Coach Signature