Client Communication Forms


At Selfaware101™ – Your Information Is Safe & Privacy Is Respected


Certain visitors to SelfAware101’s websites choose to interact with SelfAware101™ in ways that require SelfAware101™ to gather personally-identifying information. The amount and type of information that SelfAware101™ gathers depend on the nature of the interaction. For example, we ask visitors who sign up at to provide a username and email address. Those who engage in transactions with SelfAware101™ are asked to provide additional information, including as necessary the personal and financial information required to process those transactions. In each case, SelfAware101™ collects such information only insofar as is necessary or appropriate to fulfill the purpose of the visitor’s interaction with SelfAware101™. SelfAware101™ does not disclose personally-identifying information other than as described below. And visitors can always refuse to supply personally-identifying information, with the caveat that it may prevent them from engaging in certain website-related activities.


We provide two options in providing the forms that are both fast and easy to fill out and submit so that your journey can begin


You can download the PDF files directly below and fill out the requested information. Once complete, you can submit them via email to Or if you’d like, you can complete the electronic forms at the very bottom of this page – click submit, and the forms will be directly sent to SelfAware101. Whichever option you choose, it’s both safe and secure.

Electronic Communication Release Form

Coaching Agreement

Client Information Form

Additional Information



HIPPA Notice

What To Talk About With Your Coaching During Your Session

Office Directions

The Difference Between Coaching & Therapy

Selfaware101™ Electronic Communications Form

Preferred method of contact

Is it okay to text you for changes in appointments and similar issues?

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Selfaware101™ Coaching Agreement

Know Your Story…Change Your Story!™

Nancy Kay  L.P.C., C.P.C., R.N.

Licensed Professional Counselor

Certified Professional Coach

Welcome to SelfAware101™ Coaching. Below are a few guidelines that help maintain a working relationship.  If you have any questions, please don’t hesitate to call me.


1.   As a client, I understand and agree that I am fully responsible for my well-being during my coaching calls, including my choices and decisions.  I am aware that I can choose to discontinue coaching at any time.  I recognize that coaching is not psychotherapy and that professional referrals will be given if needed.

2.   I understand that “professional coaching” is a relationship I have with my coach that is designed to facilitate the creation/development of personal, professional or business goals and to develop and carry out a strategy/plan for achieving those goals.

3.   I understand that coaching is a comprehensive process that may involve all areas of my life, including work, finances, health, relationships, education and recreation.  I acknowledge that deciding how to handle these issues and implement my choices is exclusively my responsibility.

4.   I understand that coaching does not treat mental disorders as defined by the American Psychiatric Association.  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.

5.   I promise that if I am currently in therapy or otherwise under the care of a mental health professional, that I have consulted with this person regarding the advisability of working with a life coach and that this person is aware of my decision to proceed with the life coaching relationship.

6.   I understand that information will be held as confidential unless I state otherwise, in writing, except as required by law.

7.   I understand that professional coaching is not to be used in lieu of professional advice.  I will seek professional guidance for legal, medical, financial, business, spiritual or other matters.  I understand that all decisions in these areas are exclusively mine and I acknowledge that my decisions and my actions regarding them are my responsibility.

8.   I understand Nancy S. Kay is a Professional Coach and an International Coaching Federation member and she will adhere to the ICF Code of Ethics


  • FEE:     Clients pay me on time unless prior arrangements have been made.   
  • PROCEDURE: My clients call on time.  If using a Prep Sheet please email it to me prior to our session. Your prep sheet includes: updates, progress and current challenges. Let me know what you want to work on and be ready to be coached. 
  • CALLS: Our agreement includes a set amount of calls.  If you or I are on vacation, we spend more time before you/I leave and after you/I return.  Client pays for any long-distance fees if any.
  • CHANGES:  My clients give me 24 hours’ notice if they have to cancel or reschedule a call.  If you have an emergency, we will work around it.  Otherwise, a missed call is not made up.
  • PROBLEMS:  I want you to be satisfied with our relationship.  If I ever say or do something that upsets you or doesn’t feel right, please bring it up.  I promise to do what is necessary to have you be satisfied.
  • A MUST:  It is necessary for the client to implement the coaching that is given to feel that coaching is a success.  You have hired a coach to do things differently than you ever have before.  If you choose to not use the coaching and keep doing what you have always done, you will get the results you have always gotten.
  • In addition to being a professional coach, I am also a Licensed Professional Counselor in Colorado and Arkansas with training and experience in diagnosing and treating emotional problems. While there are some similarities between coaching and psychotherapy, they are very different activities and it is important that you understand the differences between them. Psychotherapy is a health care service and is usually reimbursable through health insurance policies.  This is not true for coaching. Both coaching and psychotherapy utilize knowledge of human behavior, motivation and behavioral change and interactive counseling techniques.  The major differences are in the goals, focus and level of professional responsibility. 
  • The focus of coaching is development and implementation of strategies to reach client-identified goals of enhanced performance and personal satisfaction.  Coaching may address specific personal projects, life balance, job performance and satisfaction or general conditions in the client’s life business or profession. Coaching utilizes personal strategic planning, values clarification, brainstorming, motivational counseling and other counseling techniques.
  • The relationship between the coach and client is specifically designed to avoid the power differentials that occur sometimes in the psychotherapy relation.  The client sets the agenda and the success of the enterprise depends on the client’s willingness to take risks and try new approaches. The relationship is designed to be more direct and challenging. You can count on your coach to be honest and straightforward, asking powerful questions and using challenging techniques to move you forward.  You are expected to evaluate progress and when coaching is not working as you wish, you should immediately inform me so we can both take steps to correct the problem.
  • If either of us recognizes that you have a problem that would benefit from psychotherapeutic intervention; I will refer you to appropriate resources. In some situations, I may insist that you initiate psychotherapy and that I have access to your psychotherapist as a condition of my continuing as your coach.
  • As a Professional Coach and a Licensed Professional Counselor, I am ethically and legally bound to protect the confidentiality of our communications.  I will only release information about our work to others with your written permission or if I am ordered to do so by a court order.  There are some situations in which I am legally obligated to breach confidentiality in order to protect others from harm. If I have information that indicates that a child or elderly or disabled person is being abused, I must report that to the appropriate state agency. If a client is an imminent risk to him/her self or makes threats of imminent violence against another, I am required to take protective actions.  These situations are quite rare in coaching practices. If such a situation occurs in our relationship, I will make every effort to discuss it with you before taking any action.
  • Though it is difficult I will take necessary precautions to protect the confidentiality of information which is transmitted electronically.
  • (If applicable) Some sessions are conducted in a group format. By signing this AGREEMENT, you commit yourself to maintaining the confidentiality of all of information communicated to you by other coaching clients and by your coach. 

I will strive to provide you with the best possible care. To help me meet your needs, please fill out this form completely. If you have any questions or need assistance, please ask.

Selfaware101™ Coaching Agreement Form

Are you currently seeing anyone for therapy or coaching?

Do you have any health concerns:

If the client is minor: I certify that I have the legal right to seek treatment, and do authorize Nancy S. Kay L.P.C. to provide treatment to the above registered Client. I also understand, as the parent authorizing treatment, I am responsible for payment of services provided. For Clients over 16 years of age: I authorize Nancy S. Kay L.P.C. to release schedule and billing information to the Responsible Party listed above.

This form is designed to allow you to give informed consent for the use of video technology for online therapy. Read it thoroughly for understanding and ensure all of your questions are answered before signing to give consent. This is to be used in conjunction with, but does not replace, the Informed Consent document that is required of all clients prior to starting therapy services. I understand that therapy conducted online is technical in nature and that problems may occasionally occur with internet connectivity. Difficulties with hardware, software, equipment, and/or services supplied by a 3rd party may result in service interruptions. Any problems with internet availability or connectivity are outside the control of the therapist and the therapist makes no guarantee that such services will be available or work as expected. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, I agree to call my therapist back at: 479-225-1111. I AGREE TO TAKE FULL RESPONSIBILITY FOR THE SECURITY OF ANY COMMUNICATIONS OR TREATMENT ON MY OWN COMPUTER AND IN MY OWN PHYSICAL LOCATION. I understand I am solely responsible for maintaining the strict confidentiality of my user ID and password and not allow another person to use my user ID to access the Services. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation. I understand that there will be no recording of any of the online session and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law

Payment accepted: Cash, check, or credit card - you can also pay by visiting:

Please check each box to acknowledge you agree to the additional understandings:

I voluntarily agree to receive online therapy services for an assessment, continued care, treatment, or other services and authorize Nancy Kay to provide such care, treatment, or services as are considered necessary and advisable. I understand and agree that I will participate in the planning of my care, treatment, or services and that I may withdraw consent for such care, treatment, or services that I receive through Nancy Kay at any time. By signing this Informed Consent, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

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Selfaware101™ Client Information Form

May I Leave a Message

May I Leave a Message

May I Leave a Message


Marital Status

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Certified Daring Way Facilitator Badge

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