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 selfaware101.com 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 firstname.lastname@example.org. 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
Client Information Form
What To Talk About With Your Coaching During Your Session
The Difference Between Coaching & Therapy
Selfaware101™ Electronic Communications Form
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 http://www.coachfederation.org
- 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.