Mindset & Me

Booking Form

Please provide me with more information to help me give you the best service you require.

Name

Date of Birth

Address

Phone

Are you happy to subscribe to our mailing list?

Emergency Contact

Occupation

Tell me a bit about yourself (family, hobbies, interests)?

What would you like help with?

What are your goals?

List any concerns you have?

What are your expectations from sessions?

Do you suffer from anxiety or depression? If so elaborate?

Brief medical history?

Are you taking any medications?

Disclaimer Disclaimer I have read and clearly understand the above Mindset coaching conditions.

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Disclaimer

The provision of the Mindset and Me coaching principles is intended as a tool to assist clients towards their own ultimate goals. It does in no way replace or is a substitute for professional medical or psychological assistance. Clients who have a medical or psychological disorder or illness must seek professional medical advice. This responsibility falls with the client to disclose.

The role of this coaching is to assist the client to bring balance into their whole lives and ensure the client is in touch with their own needs on a holistic level – typically the mind, body and spirit. No assumption of responsibility is made or taken through the provision of this service.

All information supplied by the client is confidential and the client may request to view their own personal information, stored in the Mindset and Me records. Information will not be given to third parties in relation to the client or the client’s personal details without the permission of the client, unless the coach deems the client, or any other person associated with the client, to be in a serious or life threatening situation, in which case is duty bound to report the perceived danger to the appropriate authorities. Such incidences may include suicidal tendencies or physical, mental or emotional abuse being committed on or by the client.