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Home
About
Rates & Insurance
Meet Latoya
Contact Us
Services
Divorce Recovery
EMDR & EMDR Intensives
Anxiety
Depression
Schedule Now
Books
Divorce Recovery Journal
Our Journal: Couples Journal
LWC Etsy Store
New Intensive Coaching Client Intake Form
Please fill out this form before your first appointment
Basic Information
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Indicates required field
Name
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First
Last
Address
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Line 1
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City
State
Zip Code
Country
Phone Number
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Email
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Date of Birth
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How did you hear about this site?
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Internet Search
Psychology Today
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Other
Financial Information
Credit Card Number
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Sessions will be charged to your credit card unless other arrangements are made. If there are issues with your credit card, you will be contacted by my office by telephone.
Expiration Date
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Verification Code on back of card.
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Billing Zip Code
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Marital Status
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Single
Married
Divorced
Widowed
Seperated
Domestic Partner
Emergency Contact
Who can I contact in case of an emergency?
Name
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First
Last
Address
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Line 1
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City
State
Zip Code
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Phone Number
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Do I have permission to contact the above person regarding your therapy?
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Yes
No
Please list any diagnoses or psychiatric medication you've taken in the past.
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List medications you are currently taking.
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Health History - Optional
Have you been in Therapy before?
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Yes
No
Do you use alcohol?
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Yes
No
Do you use Caffeine?
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Yes
No
Do you use tobacco?
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Yes
No
Do you have a history of illicit drug use?
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Yes
No
List names and ages of those you live with.
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What's your highest level of education?
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Do you have a religious affiliation or spiritual practice?
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Does anyone in your family have a history of mental illness?
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Coaching Agreement
I am excited that you have selected me as your Personal Coach to help you meet your need. This is decided to inform you of my background and of our client-coach relationship. Your signature at the end of this document is required and indicates that you agree fully to the information below. Please review carefully.
Coaching Program Contract
Each new client to my practice is a welcome addition. We have had our introductory call with each other and determined that we are optimistic and enthusiastic about what we can accomplish together. To bring our “best selves” to the coaching relationship, it is important that we share the same understanding about how we will work together.
Basic Shared Agreements:
I recommend a 3-month commitment to bi-weekly sessions (total of 6 sessions). A 3-month commitment ensures that you understand that it is hard work to change habits of thinking and acting, and that you are committed to making a concentrated effort and understand that it takes time.
Coaching Packages or Individual Sessions will be billed prior to the first session and payment needs to be received in order to begin our coaching relationship.
Each Intensive Session is 6 hours long and takes place by phone, in person or via skype.
This coaching agreement is valid as of todays date. The parties agree to engage in a VIP Intensive Coaching Session. The fee is
$ 1700
paid in advance of the initial session and
$0.00
per month based upon committed schedule. You will receive a receipt by email at the time of the charge. Print and keep these for your records. ALL SALES ARE FINAL.
I will bring myself to those coaching session free from distractions and respectfully request that you do the same. A coaching session in a public venue with distractions and background noise is not efficient.
We agree that we will each show up at the mutually scheduled time for our coaching session and if you have to reschedule you will do so with a minimum of 48 hours’ notice. I certainly understand that emergencies do arise and will accommodate those on a case-by-case basis.
Should you “no-show” for two appointments during our coaching relationship (without notification or rescheduling) we will evaluate whether or not coaching is appropriate for you right now.
If you’ve purchased a package and find yourself unable to use your sessions for any reason, you may put the remaining sessions on a 3-month hold. Session credits will not be carried out further than 3-months. Coaching fees are nonrefundable should you decide to “quit” the process, as our complimentary session is designed to remove the possibility that we would not be a good fit for each other.
I welcome communication between our calls via email (LatoyaNelsonLPC@gmail.com). It is my expectation that you will reach out if you hit a “sticky” spot that you would like some feedback on, and that you will share the successes that you have on the way to creating your desired future. If you need an “emergency call” I can usually accommodate within the same week and I do not bill for calls that are 10 minutes or less.
I welcome your input and questions along the way. Our relationship is a collaborative one, and the more you put into it the more you will get out of it. Ask me questions, challenge my point of view, bring resources to the table that you’ve found, tell me where I’m wrong, and share with me your insights along the way. You are your own best expert even if you don’t know that yet (you will shortly!).
I will call my coach at the scheduled time (919-410-6707) or meet with my coach via skype. I understand that I am responsible for any long-distance charges. I have read and agree to the working agreements above, and will honor them during our coaching relationship.
Statement of Intent
All coaching services delivered by Latoya Nelson, are meant to challenge, uplift, and support you psychologically to reach your specific goals. However, coaching is not psychotherapy. If you feel psychologically stressed to the point that it is interfering with your ability to function, please let me know and I will assist you in getting connected with a professional counselor. Life coaching may augment your therapy, but the work of coaching is meant to be done when major emotional and psychological wounds are already healing or healed. In that spirit, please read the following and sign below should you agree to each statement and wish to proceed:
I understand that the life coaching services I will be receiving from Latoya Nelson are not offered as a substitute for mental health care. I also understand that my coach, Latoya Nelson, is not acting as a psychotherapist, and does not purport to offer mental health care during the coaching sessions.
I understand that my coach will maintain the confidentiality of our communications only to the extent defined by the laws of the states in which each of us resides.
I understand and agree that I am fully responsible for my well-being during my coaching calls, and subsequently, including my choices and decisions.
I understand that all comments and ideas offered by my coach are solely for the purpose of aiding me in achieving my defined goals. I have the ability to give my informed consent, and hereby give such consent to my coach to assist me in achieving such goals.
I hereby release, waive, acquit and forever discharge Latoya Nelson and Nelson Enterprises, their agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of actions, omissions, or commissions taken by myself or by Latoya Nelson as a result of the advice given by Latoya Nelson or otherwise resulting from the coaching relationship contemplated hereunder. I further declare and represent that no promise, inducement or agreement not herein expressed has been made to me to enter into this release. The release made pursuant to this paragraph shall bind my heirs, executors, personal representatives, successors, assigns, and agents.
Confidentiality Notice
The conversations that we have within our coaching sessions are confidential and will be protected as such. Information will be shared outside of our sessions only with your written consent or in the event that a Court Judge demands it, however, the following are instances where I would be obligated by law to break our confidentiality agreement without your permission:
If it is assessed during your participation in coaching sessions that abuse or neglect of children or elders is occurring.
If in my presence you threaten to kill or harm another individual, and I am convinced that you will act on this threat, or that you may lose control of your actions.
If at any time during the course of our sessions, I determine that you are a danger to yourself, I will inform you of that opinion and make every effort to keep you from endangering your life. In some cases this may include notifying the police or family members.
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