CLIENT INFORMATION FORMS
I would like to welcome you to Lenson Life and Business Coaching. Please take the time to complete
this form as accurately as possible so that I can most appropriately address your needs

Today’s Date:

First Name:

Middle Name:

Last Name:

Address:

Apt#.

City:

State:

Zip:

Contact Information:
Home:

Cell:

Work:

ext:

Fax:

Skype:

E-Mail*:

Please indicate preferred manner for receiving communications.

Emergency contact:

Phone:

Referred by:

May I thank your referral source?

Yes

No

Gender:

Race:

Age:

Birth date:

Your time zone:

Occupation
(please be specific)

Employer:

How long at current employer:

Position:

Highest level of education:

Marital Status:

Never Married

Domestic Partnership

Married

 

Separated

Divorced

Widowed

Significant Other’s name:

Living situation:

Alone

Spouse

Lover

Parents

Friends

Other

Children:
Name:

Age:

Living in the home:

Yes

No

Name:

Age:

Living in the home:

Yes

No

Name:

Age:

Living in the home:

Yes

No

Name:

Age:

Living in the home:

Yes

No

Goal(s) you would like to achieve in Life Coaching:

History of psychotherapy or Life Coaching(and dates if applicable):

Lifestyle:
Exercise: ( Frequency )

Type:

Tobacco Use: ( Formerly )

Currently:

Alcohol/Beer/Wine/week: ( Formerly )

Currently:

Current prescription medication names:

Nonprescription drugs: ( Formerly )

Currently:

Please describe your support network: family, friends, spiritual, other:

What are the major stressors in your life?

What are your methods of coping with stress?

Is there anything you feel is important for me to know about you or your situation?

Please sign and date this Client Information Form:
Signed:

Print name:

Date:

(Must be cosigned by adult if under 18 years old):
Signed:

Print name:

Date:

Relationship to minor:

LENSON LIFE COACHING – CLIENT SERVICES AGREEMENT

This document constitutes a contract between us. You should read it carefully and raise any questions or concerns before you sign it.

The services provided are coaching or tele-coaching as provided with you, as client. In our Life Coaching sessions, we will jointly agree upon issues you wish to work, and goals you wish to set up for yourself. While Life Coaching is generally beneficial, there are no guarantees of how you will experience Life Coaching. It is important that you openly discuss any dissatisfaction or concerns so that we can make the necessary adjustments in meeting your goals.

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 of clarification, brainstorming, motivational counseling, and other counseling techniques.

Life coaching does not diagnose or treat mental and nervous disorders. Coaching is not reimbursable through health insurance policies, as psychotherapy often is.

APPOINTMENTS, HOURS AND LOCATION

Individual sessions are approximately 60 minutes, and can be scheduled by contacting me at (949)244-5100, or via email at Eileen@LensonLifeCoaching.com. Sessions can be conducted on the telephone, or at a mutually agreed to location. Travel over 30 minutes to a meeting location may result in travel fees.

CANCELLATION POLICY

If you need to cancel or reschedule the session, please give 24-hour notice. We will reschedule to a mutually acceptable time. Emergencies will be dealt with as they arise. Forgetting or missing an appointment or call is not an emergency. Missed appointments or non-emergency cancellations with less than 24-hour notice will be billed at the normal rate.

EMERGENCY ACCESS and TELEPHONE CALLS

Lengthy telephone calls will be subject to regular session consultations and may be prorated and billed at my standard hourly rate for professional service. If you are experiencing an emergency, please call 911 or go to a hospital emergency room.

CONFIDENTIALITY

I will be maintaining a client record on your case, which is the property of Lenson Life Coaching. In specific situations, I am required to disclose information without your consent or authorization to authorities. This includes, but is not limited to, situations in which a client appears to be at risk to himself or others, if abuse or neglect is suspected, and if the court orders or subpoenas Lenson Life Coaching to disclose information. These situations are quite unusual in coaching situations, and if it does arise I will make every effort to discuss it with you prior to taking the protective action. Unless otherwise indicated by a court order, if the client is a minor, both parents have the right to access of the minor’s records. If a client files a complaint or lawsuit against Lenson Life Coaching, the records will be shared openly.

It is impossible to protect the confidentiality of information that is transmitted electronically. This is particularly true of e-mail and information stored on computers.

FINANCIAL TERM

Fees for coaching telephone sessions are to be made through PayPal prior to each session. Face to face sessions may either be paid through PayPal in advance or in person at the time of the session. A receipt for your records will be provided in either case.

Lenson Life Coaching reserves the right to collect any unpaid balance and may use a collection agency or take legal action to secure payment, as authorized by state or federal law, and the collections action will become a part of your credit record.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. IT ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE THE OPTION TO TERMINATE YOUR PERSONAL COACHING RELATIONSHIP AT ANY TIME.

For consent forms completed online, please read below:

BY CLICKING THE “I ACCEPT” BUTTON LOCATED AT THE END OF THIS AGREEMENT THAT APPEARS ONLINE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS OF THIS AGREEMENT. IF YOU DO NOT AGREE WITH ALL THE TERMS OF THIS AGREEMENT AND DO NOT AGREE TO BE BOUND BY THIS AGREEMENT, PLEASE CLICK THE “I DO NOT ACCEPT” BUTTON. IF YOU DO NOT ACCEPT THIS AGREEMENT, YOU WILL NOT RECEIVE LIFE COACHING FROM EILEEN LENSON.

BY CLICKING ON THE “I ACCEPT” BUTTON, YOU ACKNOWLEDGE THAT (1) YOU HAVE CAREFULLY READ AND REVIEWED THE TERMS AND CONDITIONS OF THIS AGREEMENT IN ITS ENTIRETY, (2) YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS OF THIS AGREEMENT, (3) THE INDIVIDUAL SO CLICKING HAS THE POWER, AUTHORITY AND LEGAL RIGHT TO ENTER INTO THIS AGREEMENT ON BEHALF OF YOU AND, (4) BY SO CLICKING, THIS AGREEMENT CONSTITUTES BINDING AND ENFORCEABLE OBLIGATIONS OF YOU.

I Accept

I Do NOT Accept

Last Name:

First Name:

Middle Name:

Date:

Name of minor if client is under 18 years of age:
Last Name:

First Name:

Middle Name:

Minor’s birth date:

Age:

Gender:

Male

Female

If a minor child is under Conjoint Legal Custody then both Parents need to consent to being seen by Life Coach:
Signature of Parent/Guardian:

Date:

Signature of Parent/Guardian:

Date: