#0 (ALL 1-on-1 TRAINERS – Template) PART 1 DOC PIPELINE (This Form -> Information Release Intake Form)

ConneXions Training

Helping people maximize their potential and achieve their goals

Policies and Procedure

Welcome!

Welcome to the ConneXions Training experience and working together as client and Mental Fitness Trainer. ConneXions wishes to share some items to facilitate a synergistic relationship with you and your trainer. If you have any questions, please call us.

YOUR PREFERRED TRAINER

Trainer Name*

*

FEE

Clients pay prior to their session unless other arrangements have been made. Payment may be made by cash, check or credit card.

PROCEDURE

Clients arrive to their appointment on time.
It is your responsibility to let the trainer know what you want to work on, and be ready to be trained.
The agenda is client generated and trainer supported.

SESSIONS

Our agreement includes one or more 50-sessions.

CHANGES

Clients must give their trainer 48 hours notice if they need to cancel or reschedule a session. A missed session is forfeited, and you will be charged for the full amount of the session. For example, your appointment is Monday at 10am, you would need to cancel Thursday by 10am to give notice of 48 business hours.

EXTRA TIME

You may call between sessions if you need “spot training”/have an issue. Phone sessions will be billed at a prorated amount according to the amount of time of the phone call.

PROBLEMS

ConneXions wants you to be satisfied with your relationship with your trainer. If your trainer ever says or does something that is confusing to you or doesn't feel right, please bring it up. You are responsible to let us know of the conflicts you feel.

A MUST

To feel that training is a success, it is necessary for the client to implement the training that is given. You have hired a trainer to do things differently than you ever have before. If you choose to not use the training and keep doing what you have always done, you will get the results you have always gotten.

Training Agreement & Informed Consent

Welcome to ConneXions Training, a professional training company. This document and its attachments constitute a contract between us (the "Agreement"). You should read it carefully and raise any questions or concerns that you have before you sign it.

Services

The services provided by ConneXions include Training or TeleTraining on topics decided jointly with you, the client. The purpose of training is to develop and implement strategies to help you reach personally identified goals of enhanced performance and personal satisfaction. Training may address a wide variety of goals including specific personal projects, life balance, job performance and satisfaction, or conditions, situations or experiences in your life, business, or profession. This is NOT psychotherapy. This is not therapy and no therapist patient relationship is created.

What is Training?

Training is an interaction that occurs between people that produces desired performance, change or transformational results by promoting personal and organizational awareness, purpose, competence and well-being. Training is focused on enhancing performance, generating personal change and development of the whole person not separate from the systems of which they are a part. A trainer is a person participating in a mutually voluntary interaction with neither responsibility, accountability nor authority over the outcomes of the person being trained.

In each session, the client chooses the focus of conversation. This interaction creates clarity and invites the client into action. Training accelerates the client’s progress by providing greater their choices, responsibility and humility. Training concentrates on where clients are today and what they are willing to do to get where they want to be.

Mental Fitness Training is a powerful human relationship which assists people to design their future and understand their present rather than "get over their past." Through a long-term relationship, trainers aid clients in creating visions and goals for all aspects of their lives and create multiple strategies to support them achieving these goals. Trainers recognize the brilliance of each client and their personal power to discover their own solutions when provided with wisdom, accountability and validation. The client can count on the trainer to be honest and direct in asking questions and inviting change.

Training vs. Psychotherapy

Although there are some similarities between training and psychotherapy, ConneXions does not conduct psychotherapy with its training clients. These are different activities, and it is important that you understand the differences between them.

There are major differences in the goals, focus, and level of professional responsibility. As a trainer, our responsibility is to assist you to (1) make decisions about which changes you would like to make (2) to develop a personal “action plan” in order to make those changes, (3) to implement your action plan and make the behavioral changes, (4) to develop strategies to maintain the changes you have made, and (5) educate you about the power and principles of honesty, personal responsibility and humility, which will create a stable foundation for you to choose from. Trainers will support, encourage, teach, and direct you to stay "on track" toward your goals.

Your success will depend on your willingness to define, take risks and try new approaches. You can expect your Trainer to be honest and direct asking straightforward questions and using challenging techniques to help you move forward. Like any human endeavor, training can involve feelings of distress and frustration that accompany the process of change.

Psychotherapy is a health care service. Its primary focus is to identify, diagnose, and treat nervous and mental disorders. Connexions Training does NOT identify, diagnose, and treat nervous and mental disorders.

Payment Procedure:

This agreement, between trainer and the above-named client will begin on

Date*

*.

The fee for each 50-minute session is $

The fee for the initial meeting is $*

* (plus 3% processing fee).

If you choose to cancel within 48 business hours of your set appointment (not including weekends) you will be charged for your 50-minute appointment. For example if, your appointment is Monday at 10am, you would need to cancel Thursday by 10am to give notice of 48 business hours of your appointments cancelation. The Trainer is paid in advance of each series of training appointments. Your first training session will begin after ConneXions receives your signed agreement and your payment. You may pay by cash, credit card (Discover, Visa, MC) or check. Services requested by the Client in addition to training calls, will be billed at a prorated hourly rate (agreed in advance) and will be paid before services are performed.

Call Procedure:

If the Client chooses to be trained by telephone, Zoom or Skype, the Trainer will call the Client at the prearranged time as scheduled. Your session will be 50 minutes in length. For example: if the session begins at 2pm, be prepared at 2pm. The Trainer will begin the session between 2pm to 2:10pm to ensure the 50 minute session length.

Cancellations:

Please remember you must give 48 business hours prior notice if you need to cancel or change the time of an appointment; otherwise you will be charged for the session in full. For example if, your appointment is Monday at 10am, you would need to cancel Thursday by 10am to give notice of 48 business hours of your appointments cancelation.

Termination:

Either party may end the training relationship by providing the other party with a one-week written notice, which may be transmitted by email, fax or in person.

Training Completion:

Connexions Classroom’s trainers, utilize proprietary methods, approaches, and techniques that have developed and honed over many years. Because of this, the training sessions that you will participate in offer cutting edge techniques that are confidential, proprietary and owned exclusively by Connexions Classroom. By undertaking training with Connexions Classroom, you agree that you will not in any way (a) attempt to replicate, encourage or support training sessions using the information, techniques, or methods used by Connexions Classroom with any persons; (b) replicate any of the materials, methods, or approaches in which you participate for any purpose (whether for free or for compensation); and (c) otherwise utilize any of the techniques or methods to train any third persons without written permission from Connexions Classroom. You agree that if you violate this portion of this agreement, it will lead to irreparable injury to Connexions Classroom and therefore injunctive relief is warranted and appropriate and you waive any defense that there is a legal remedy available to Connexions Classroom in place of this injunctive equitable relief. You further agree that said injunctive relief may be sought exclusively in the Fifth District Court in and for Washington County, State of Utah and that Connexions Classroom shall be entitled to all attorneys’ fees and costs incurred in pursuing such injunctive relief.

Your signature below indicates that you have read the information in this document (“Training Agreement and Informed Consent”) and any attachments, such as the Training Fee Plan, and agree to abide by its terms during and after our professional Training relationship.

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Trainer*

Trainer Name*

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ConneXions Training
Teleconferencing Software Informed Consent

Having been fully informed of the risks listed below, I

Name*

*

hereby give my informed consent to use Zoom, Skype and/or other teleconferencing software to facilitate training sessions with an agent of ConneXions Classroom. Having been informed of the risks of using such software, I, in my sole discretion, request that my ConneXions Trainer utilize such software to facilitate my training sessions.

Risks include but are not limited to:

With the use of any teleconferencing software, there is inherent risk of eavesdropping and/or accidental information disclosure. Although ConneXions Trainers do all within our power to ensure the privacy and confidentiality of our clients, nobody can eliminate all risks of electronic information disclosure through the use of teleconferencing software.
The use of teleconferencing software requires trust and good faith in the professionalism, trustworthiness, and cybersecurity expertise of multiple outside parties, including, but not limited to, the manufacturers of all utilized computer hardware, operating systems and software (including the teleconferencing software). All of these parties are outside the control of ConneXions Classroom.
The use of teleconferencing software necessitates the use of your (the client's) computer hardware and software. Such hardware and software are your responsibility to maintain and are entirely out of the control of ConneXions Classroom. In no case will ConneXions Classroom or any ConneXions Trainer be held liable for information disclosure or breaches of confidentiality arising from cybersecurity breaches of your computer equipment, or from negligence, misuse or misconduct involving you or your computer hardware or software, whether caused by you or by others.
All Internet-connected technologies present the risks inherent in connecting to the global, publicly-accessible Internet. Software systems of all varieties have been compromised by hackers and other unauthorized agents. Even systems owned by highly-responsible parties such as banks, governments, and militaries—and operated following the most rigorous and complete security practices—have been compromised by bad actors, causing unauthorized access and/or information disclosure. The use of any Internet-connected technology presents such risks.
Privacy, confidentiality and cybersecurity are shared responsibilities. Security breaches (such as password leaks) in other websites or Internet services may impact the security and privacy of your teleconferencing experience. Unauthorized access to your computer may likewise impact the privacy, confidentiality and security of other clients of ConneXions Classroom, who also request to use teleconferencing software. Due to the nature of cybersecurity, your confidentiality can be breached if other users of the teleconferencing system experience a cybersecurity breach or through negligence allow unauthorized access to their teleconferencing software. ConneXions Classroom and your ConneXions Trainer will in no case be held liable for the actions of you or other clients, and if you request to utilize teleconferencing software, you do so having been fully informed of such risks. ConneXions Trainers expect and encourage all people to be responsible for the risks they choose to take.

I understand that my relationship with ConneXions Classroom and any of its agents DOES NOT CONSTITUTE A THERAPEUTIC RELATIONSHIP. I have chosen to participate in training with ConneXions Classroom. I understand that the training relationship is different from a psychotherapeutic or counseling relationship. The psychotherapeutic relationship places the professional in a position of legal authority and power over the patient. On the other hand, the training relationship seeks to eliminate this power differential, and places total power and responsibility for decisions and outcomes in the hands of the client. Responsibilities (such as confidentiality) that would rest solely on the therapist in a psychotherapeutic relationship are instead shared responsibilities in a training relationship. As a training client, therefore, I understand and agree to take on an added level of trust to maintain the confidentiality of myself and any other clients who may be involved in any teleconferences in which I participate. I understand that my actions do and will affect others, and it is my responsibility to educate myself on responsible use of teleconferencing software and Internet-connected technologies generally, in order to protect myself and others during and after this Internet-mediated training experience.

I agree to indemnify and hold harmless ConneXions Classroom and all of its agents in the event of any information disclosure or breach of confidentiality arising from the use of teleconferencing software, including but not limited to cybersecurity breaches, hacking attacks, and other types of unwarranted information access. I agree to be responsible for my choice to conduct meetings with ConneXions Trainers via teleconferencing software, and I accept all risks associated therewith, whether known or unknown at the time of signing this document. I accept that there are no guarantees in life, and I agree to use prudence, awareness and good sense and conduct myself wisely and responsibly in my use of teleconferencing software, in order to protect my confidentiality and the confidentiality of any and all others who may also choose to teleconference with ConneXions Classroom.

Signature*

Date*

CONNEXIONS CLASSROOM INTAKE FORM

Date*

Social Security No.

Name*

Date of Birth*

Age*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone Numbers:

Cell Phone:*

Cell Phone*

Daytime Phone:*

Daytime Phone*

Evening Phone:*

Evening Phone*

Fax Line:

Fax Line

Email Address:*

Email Address*

Okay to leave messages everywhere?*

Yes
No

If not, explain:*

Preferred means of communication:*

Other Significant Dates:

Preferred Training Schedule: (day of the week)*

Preferred Training Schedule: (day of the week)

[or] (time of day) *

[or] (time of day)*

:

Occupation*

Highest Level of Education*

Emergency Contact*

Cell Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Relationship*

Do You Hold Any Professional Licenses or Certifications?*

Yes
No

by What Organization?*

What Organization?*

With Whom Do You Now Live? List People and Relationship(s)

Name	Relationship

Signature:*

Signature*

Date:*

Date*

Names of important people in your life (spouse, partner, children, friends, etc.):*

Name (s)	Relationship

Click the + icon to add more list

Other information you want us to know:*

How did you hear about our training services?*

What influenced your decision to work with a trainer?*

Have you ever been trained?*

Yes
No

If so, please describe the experience.*

What specific goals would you like to accomplish in the next three months?*

What one major goal would you like to address within the next 12 months?*

What are your significant concerns?*

What are your dreams?*

What dreams have you given up on?*

Where do you want to focus first?*

What parts of life are working best now?*

What parts of life are working least well?*

What are your values?*

What stops you from having the life you want to have?*

YOUR LIFE STORY

(Please write in any style you desire and be as creative as you want. Detail any important aspects, accomplishments, highlights that you feel are important for me to know. Please send this with a recent picture if we are training by phone.)

Life Story*

THE FIRST STEP: DE-CLUTTERING (OPTIONAL)

We put up with, accept, take on, and are dragged down by people and situations that we may have come to ignore in our lives rather than fix them. Now is the time to identify those things that drain your energy for positive activities. As you think of more items, add them to your list.

You may or may not choose to do anything about them right now, but just becoming aware of and articulating them will bring them to the forefront where you’ll naturally start eliminating, fixing or resolving them.

ENERGY DRAINERS AT WORK	ENERGY DRAINERS AT HOME

Click + icon to add lists

BALANCING YOUR LIFE (OPTIONAL)

Place a value from 1-10 in each sector representing the degree of fulfillment you experience in each area.

MISSION STATEMENT OF VALUES (OPTIONAL)

Spirituality

Community Service

Health & Fitness

Family & Friend Relationships

Recreation

Finances

Career & Job

Personal & Intellectual Growth

TEMPLATE FOR PERSONAL VISION STATEMENT (OPTIONAL)

We at Connexions strongly believe that we are each the creator and director of our own life drama, able to create “on purpose” what our life will look like, feel like, and be like.

It is your opportunity and responsibility to write the script, be the producer and director, and to gather the other characters in your life drama. Some people live painful dramas or unfulfilling dramas, but if you are conscious and on purpose with what you want your life to be, it has a much greater chance of evolving into your vision.

So how does one begin designing one’s life? First of all you can begin to revisit and remember dreams and desires from your younger years. What drove you? What did you want to become? Who did you admire? Divide your life into thirds and ask yourself what accomplishments or happy events occurred in each third of your life? What values were represented? Are those values still present?

Exercise: My personal lifestyle

Read through the following sentences and answer as if your life were exactly as you would like it to be. Let this be an accurate reflection of what you envision for your ideal life. After you have completed all these pieces of your Personal Vision, you can write a summary paragraph that encapsulates all your intentions, desires and values.

1. In my family life I am committed to

(spending time with, enjoying, teaching, working with, taking care of) my (spouse, partner, friends, family and/or children).

2. For recreation and fun, I enjoy

3. My home environment will be

(nurturing, comfortable, a place for entertainment, on the water, spacious, have a home office, in the city, in the country, etc.)

4. My retirement home will be

(a cabin in the mountains, a seaside condo, a small restored Victorian home, a large, spacious home to accommodate visiting grandchildren and guests, a large motor home, a houseboat.

5. My hobbies, passions, interest are

(world travel, politics, reading, writing, sports, gardening, martial arts, etc.)

6. I will maintain (or regain) my health by

(exercising, eating healthy foods, lowering my stress, meditating, etc.)

Exercise: My professional life

1. I will concentrate my practice in the areas of

(fill in with niche or types of clients).

2. My office environment will be

(spacious, comfortable, a home office, efficient, well-organized, etc.)

3. My financial plans are to

(earn a minimum of _______ per year, save 20% of my income, leverage my investments to retire at age ____ allow for 4 vacations a year, buy a retirement home, etc.)

4. My business philosophy is one of

(integrity, leadership, dedication to my clients, providing superior training and modeling for my clients, being known as an expert in my specialty, etc.)

PERSONAL VISION WORKSHEET (OPTIONAL)

Using the information you have gathered about yourself in the preceding exercises, write your personal Vision in paragraph from. You may do a rough draft and then polish it in the weeks to come.

GOALS (OPTIONAL)

What goals, aspirations, desires, and intentions do you want to accomplish in the first six months of mental fitness training?

In my personal life I am committed to...

Business:

Personal:

What do you want to accomplish, change, or create in the first 30 days of mental fitness training?

Business:

Personal:

What I hope to gain from this training relationship:

Other things I’d like my trainer to know about me:

Fill out ALL FORMS below TO CONFIRM your 1-on-1 training session.

Your session will officially be confirmed AFTER these forms are completed.

ConneXions Training

Policies and Procedure

Welcome!

YOUR PREFERRED TRAINER

Training Agreement & Informed Consent

ConneXions Training
Teleconferencing Software Informed Consent

CONNEXIONS CLASSROOM INTAKE FORM

YOUR LIFE STORY

THE FIRST STEP: DE-CLUTTERING (OPTIONAL)

BALANCING YOUR LIFE (OPTIONAL)

MISSION STATEMENT OF VALUES (OPTIONAL)

TEMPLATE FOR PERSONAL VISION STATEMENT (OPTIONAL)

PERSONAL VISION WORKSHEET (OPTIONAL)

GOALS (OPTIONAL)

LEARN

BUSINESS

Fill out ALL FORMS below TO CONFIRM your 1-on-1 training session.

Your session will officially be confirmed AFTER these forms are completed.

ConneXions Training

Policies and Procedure

Welcome!

YOUR PREFERRED TRAINER

Training Agreement & Informed Consent

ConneXions TrainingTeleconferencing Software Informed Consent

CONNEXIONS CLASSROOM INTAKE FORM

YOUR LIFE STORY

THE FIRST STEP: DE-CLUTTERING (OPTIONAL)

BALANCING YOUR LIFE (OPTIONAL)

MISSION STATEMENT OF VALUES (OPTIONAL)

TEMPLATE FOR PERSONAL VISION STATEMENT (OPTIONAL)

PERSONAL VISION WORKSHEET (OPTIONAL)

GOALS (OPTIONAL)

ConneXions Training
Teleconferencing Software Informed Consent