Organization Coaching Client Registration Form

Date *

Client Information

Last Name *

First Name *

Phone Number *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Church, Group, or Organization *

Position/Title

Living Arrangement *

If, "Other", please specify.

Spouse *

Children's Name and Age *

Emergency Contact Name *

First

Last

Emergency Contact Number *

What is the nature of the work you do? *

Do you have a preferred coach? *

Yes
No

Learn more about The Resilience Resource Team here: https://theresilienceresource.org/who-we-are/

Please choose one: *

*Online scheduling is available

Client Questionnaire

The goal of coaching is, in partnership with your coach, to support you in processing day to day or crisis events, assess signs and symptoms you may be experiencing, talk through strategies of care, and lay out a path for healing and resilience building. The agenda of each coaching session is set by the client. We then work together to gain new insights and structure for the effective implementation of your goals.

Have you had any negative experiences with coaching or therapeutic services? *

Yes
No

Please explain your past negative experiences with the service. *

Please describe any current concerns that you would like to address. *

What do you want more of in your life right now? *

What do you want less of in your life right now? *

What keeps you up at night? *

How did you hear about us? *

Please specify. *

Coaching Terms and Conditions

As a client, I understand and agree that I am fully responsible for my well-being during my coaching sessions, including any choices and decisions that I make.
I understand that “coaching” is a partnership I have with my coach that is designed to holistically assist in processing experiences and events, assess current signs and symptoms I may be experiencing, and to facilitate the creation and implementation of personal or professional goals.
I understand that personal coaching is a comprehensive process that may involve all areas of my life, including but not limited to: work, finances, health, relationships, education, personal development, spirituality, and recreation. I acknowledge that deciding how to deal with these topics and implement my choices is exclusively my responsibility.
I understand that all decisions in these areas are exclusively mine, and I acknowledge that my decisions and actions regarding them are my responsibility. I understand that I am always free to reject any ideas, insights, perceptions, or requests made by my coach at any time.
I understand that personal coaching is not to be used in lieu of professional advice. I will seek professional or clinical guidance for legal, medical, psychological, financial, business, religious, or other matters.
I understand that personal coaching does not treat mental disorders as defined by the American Psychiatric Association. I understand that personal coaching is not a substitute for counseling, psychotherapy, psychoanalysis, clinical mental health care, or substance abuse treatment, and I will not use it in place of any form of such therapy. I further understand that if topics arise that I or my coach believe would best be served by seeing a mental health professional, an appropriate referral will be made. If I am under the care of a mental health professional, I will consult with him/her regarding the advisability of working with a coach and will let them know of my decision to proceed with the coaching relationship.
I am aware that I can choose to discontinue coaching at any time.
I will contact my coach at least 24 hours in advance to reschedule a session. Any cancelation of a session with less than 24-hour notice will result in forfeiting the session.
I understand that sessions are generally scheduled on a two-week rotation. If I need to reschedule, I understand that I will need to reschedule following every two-week rotation unless a spot becomes available the following week.
I understand that my coach will maintain the confidentiality of our coaching relationship within the requirements of the law unless I have given written permission to use my name in testimonials or other public domains. I also understand that to protect myself and others, exceptions to confidentiality will include risk of harm to myself or others, or admission of involvement in a major crime.
I understand that the coach engages in training and continuing education to pursue and/or maintain coaching credentials.

The coaching process requires the names and contact information of all clients for the confidential records of The Resilience Resource. By signing this agreement, you agree to have your name, e-mail address and start & end dates of coaching shared with The Resilience Resource team for the sole purpose of verifying the coaching relationship. No other information, including notes, will be shared. You are also agreeing to have certain topics anonymously and hypothetically shared with other coaching professionals for training or consultation purposes.

Acknowledgement *

I have read and agree to the terms and conditions of the coaching agreement