Name

Call-Number

Text / Cell Number

Email Address

Preferred method of contact Preferred method of contact Text Email Call

Is it okay to text you for changes in appointments and similar issues? Is it okay to text you for changes in appointments and similar issues? Yes No

Please Type Name + Last 4 Numbers of Phone Number Listed Above To Act As Your Signature

Date Submitted

Name

Date Submitted

Who referred you?

What is you reason for seeking coaching?

What do you hope to accomplish from coaching?

List all previous therapy and coaching experiences:

Are you currently seeing anyone for therapy or coaching? Are you currently seeing anyone for therapy or coaching? Yes No

If yes, whom:

Do you have any health concerns: Do you have any health concerns: No Yes

If yes, please list:

List any medications you are currently taking:

Responsible Party For Payments Name :

Responsible Party Street Address

Responsible Party City

Responsible Party State

Responsible Party Zip Code

Responsible Party Home Phone

Responsible Party Work Phone

Email Address:

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. 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. Yes No

Please type name and last four digits of phone number listed to act as signature and authenticate:

Date Submitted

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 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 I agree I disagree

Please type name and last four digits of phone number listed to act as signature and authenticate:

Date Submitted

Fee for session:

Duration:

Payment accepted: Cash, check, or credit card - you can also pay by visiting: https://selfaware101.com/product/1-on-1-personal-coaching/ Payment accepted: Cash, check, or credit card - you can also pay by visiting: https://selfaware101.com/product/1-on-1-personal-coaching/ I acknowledge that all forms of payment are accepted

Please check each box to acknowledge you agree to the additional understandings: Please check each box to acknowledge you agree to the additional understandings: All fees are to be paid prior to service If extra assessments are taken, client will be charged a fee for the administration of any assessment tool

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. 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. I agree I disagree

Please type name & last 4 digits of phone number to act as signature

Parent, Guardian, or Legal Representative Signature - Please type name & last 4 digits of phone number to act as signature

Date of Signature

Last Name

First Name

Middle Initial

Street Address

City

State

Zip Code

Name of Parent(s) / Guardian(s) - if applicable

Home Phone

May I Leave a Message May I Leave a Message Yes No

Cell Phone

May I Leave a Message May I Leave a Message Yes No

Work Phone

May I Leave a Message May I Leave a Message Yes No

Email Address

Date of Birth

Age

Gender Gender Female Male

Marital Status Marital Status Never Married Married Domestic Partner Seperated Divorced Widowed

Please list any children and their age(s)

Name of other health care provider (Primary Care Physician, Psychiatrist, etc.)

Provider's Role In Your Healthcare?

Name of other health care phone number

Name of other health care provider (Primary Care Physician, Psychiatrist, etc.)

Provider's Role In Your Healthcare?

Name of other health care phone number

Emergency Contact Name

Emergency Contact Relationship to Patient

Emergency Contact Address

Emergency Contact Phone

Referred By

Referral Phone Number