305-330-5200

1. Intake 

2. Initial assessment

3. circle of life wheel


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1. INTAKE FORM

We are excited to be your coach, and look forward to getting to know you. Please complete the following information. It includes your Demographics, an Informed Consent, our Confidentiality Agreement and Financial Responsibility. Talk to you soon. 

Gender
May we contact you via text
Marital Status
Doctor, Family, Friend, or other Google Search, etc.
INFORMED CONSENT*
Life Coaching is an educational program. It is not intended as therapy or treatment, or to replace therapy or treatment. It will not treat issues related to substance abuse, suicidal or homicidal thoughts, nor any mental health disorder. At times, some highly charged emotional experiences may occur. Coaching may elicit responses such as anger, sadness, desire, pleasure, joy, love, pain, and fear. These experiences are part of the coaching because the goal is to expand options for understanding, fulfillment and empowerment, as well as enhance the capacity for empathy and joy. It is always the option of each individual to participate in any of the coaching exercises offered, or to choose not to participate. I agree to hold Circle of Life Coaching, its officers, representatives, and subcontractors harmless against any claims related to my experience. I understand that the coach may audio or videotape class lectures or workshops, which may be reviewed for quality and/or research purposes. Such audio or video will not identify participants in any way.
CONFIDENTIALITY AGREEMENT*
I understand that coaching is a private and personal experience for each participant. As such, I agree to respect the confidentiality of all participants and their remarks and actions, and I agree to keep all such information private and confidential. I also understand that all written materials are protected by copyright, and cannot be reproduced, copied, stored electronically or otherwise duplicated or distributed without the expressed written consent of Circle of Life Coaching. I agree not to violate this copyright.
FINANCIAL & CANCELLATION*
Client or Legal Guardian agrees to make payment PRIOR to each session. Client understands if it is necessary to cancel an appointment, it is the responsibility of the client to notify Circle of Life Group 24 hours in advance, otherwise, a $45 fee will be charged. Once we have scheduled an appointment, please arrive on time. If you are late for a scheduled appointment without proper notice, you may be charged for that time.
By signing below I declare that all of my responses are accurate and true to the best of my knowledge; and that I have read and understand the Informed Consent, Confidentiality Agreement and Financial Responsibility/Cancellation Policy and agree to abide by the terms of each.
SUBMIT
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2. INITIAL ASSESSMENT FORM


Specific complaints. Include duration of each -estimate if unknown.
Have you ever had this problem before, when you were a kid?
(Include prior treatment for psychiatric and/or substance abuse problems, including hospitalizations, etc. Please indicate if history was gathered from client, record, facility staff, or family)
Estimate if unknown
Mental Illness
Are parents alive or deceased? Are you parents together, separated, or divorced? If parents are divorced, did they remarry?
Number of children, step-children, and their ages.
Number of siblings, male or female and their ages.
"I feel .......
History of Substance Abuse
Do you Smoke
Suicidal Thoughts
If yes, please explain including when and how
Homicidal Thoughts
coach to know
SUBMIT
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3. CIRCLE OF LIFE WHEEL

On a scale of 1-10, (1 being completely unsatisfactory, as in a disaster and 10 being thoroughly satisfied, as in you love this area, it couldn't be better), decide where you perceive yourself to be in each area of your life at the present time. Write that number next to the appropriate area. 

Significant other / Love life or lack of
Health
Self-Esteem / Self-Worth / Self-Image
Career
Faith
Travel / Leisure Time
Name area not listed above
about any of the above life areas?
SUBMIT
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