Name
*
First Name
Last Name
Chosen name/preferred name/nickname
Pronouns
*
They/them
She/her
He/him
Email Address
*
Phone
*
Country
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Emergency Contact (Name, phone number, and relationship to you, please!)
Are you currently working with a therapist? If yes, for how long?
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Have you been diagnosed with mental or emotional instability by a mental health professional? If yes, what is your diagnosis? (While I don't adhere to a diagnosis-based approach to mental and emotional wellness, it's important for me to know your background in this area.)
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Are you currently taking any medications prescribed for mental or emotional support? If so, what?
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Have you experienced what you'd describe as an emotional crisis recently? If yes, please describe.
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Have you done this kind of coaching work before? If yes, with whom? If no, what makes now the right time?
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Is there a primary topic or concern you'd like to make sure we talk about? If you've signed up for The One-Off, please provide me with a thorough description (as detailed as possible) about what you'd like to focus on.
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What are some things that hook or trigger you? (I'm not necessarily going to avoid these things, but want to be mindful of extra-sensitive spots.)
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If we're successful in our work together, what will be different?
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Is there anything else you think I should know? Don't be shy.
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By checking this box I acknowledge that I am embarking on transformational life coaching work, and that this work is not therapy. I agree that if I need support managing acute emotional distress, I will reach out to an appropriate mental health or crisis professional in my area. I acknowledge that if through the course of our work together I state a clear intention to kill myself or anyone else, Emily Ballard is legally bound to report this information to the proper authorities in my area. I acknowledge that this work is not intended to support acute emotional distress or ongoing management of mental health symptoms, and I release Emily Ballard from responsibility for the management of my mental and emotional health. I acknowledge that the nature of coaching and other support work is fluid, which in this case means the coach (Emily Ballard) and I (the client) may jointly agree to stray from the stated content of the package I have purchased if we feel this is most beneficial for my (client’s) well-being. I recognize that this does not equal breach of contract, but a mutually agreed upon shift in direction. I recognize that I am agreeing to pay for the package I have signed up for in full. I understand that if I (client) have entered into a payment plan with Emily Ballard, that I (client) may be paying for services rendered after those services are received. I understand that all coaching packages purchased via Emily Ballard are non-refundable, and that if I choose not to complete my package for any reason, I will not be refunded for unused sessions. I (client) acknowledge that I understand the stated payment arrangement with Emily Ballard, and I agree to the terms.
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Welcome to your standard, required legalese-y statement.
PS: How'd you find me?
