First Name
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Last Name
*
Email
*
Phone
*
(###)
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####
Birthday
MM
DD
YYYY
Gender
Occupation
Are you currently married?
Yes
No
How Long Have You Been Married?
Spouse Name
Number of Pregnancies
Do you have any living children?
Are you a Christian?
Do you have a church that you attend?
How often do you attend church?
How often do you read the Bible?
How often do you pray?
Do you have any medical or physical problems that affect you emotionally?
Please describe your primary reasons for seeking coaching and what you hope to gain.
Disclaimer
*
I understand that the coaching services I will be receiving from Foreknown Ministries and/or my Coach are not offered as a substitute for professional mental health care or medical care and are not intended to diagnose, treat or cure any mental health or medical conditions. I also understand that my Coach is not acting as a mental health counselor or a medical professional.
I understand that coaching is, at present, an unregulated industry and that my Coach is not licensed by the State of Colorado. I also understand that for all legal purposes, the services provided by my Coach will be considered to be provided in the state of Colorado.
I understand and agree that I am fully responsible for my well-being during my coaching sessions, and subsequently, including my choices and decisions.
I understand that coaching is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care, or substance abuse treatment, and I will not use it in place of any form of therapy.
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 understand that to the extent our work together involves faith, family, career, or business, my Coach is not promising outcomes including but not limited to increased clientele, profitability, and/ or business success.
I understand that my Coach will protect my information as confidential unless I state otherwise in writing. If I report child, elder abuse or neglect or threaten to harm myself or someone else, I understand that necessary actions will be taken and my confidentiality agreement limited in this capacity. Furthermore, if my Coach is ordered by a court to provide information or to testify, (s)he will do so to the extent the law requires.
I understand that the use of technology is not always secure and I accept the risks of confidentiality in the use of email, text, phone, Skype, and other technology.
I hereby release, waive, acquit and forever discharge Foreknown Ministries and my Coach, any agents, successors, assigns, personal representatives, executors, heirs, and/or 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 acts or omissions by myself or by my Coach as a result of the advice given by my Coach or otherwise resulting from the coaching relationship contemplated by this agreement. I further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made to me to sign this agreement.
After the completion of a coaching session, under no circumstances are refunds issued. Coaching appointments can always be rescheduled prior to the originally scheduled appointment.
This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents.