Client Intake for ConneXions Coaching

Step 1 of 9 - Policies and Procedure

ConneXions Coaching
Helping people maximize their potential and achieve their goals
Policies and Procedure

Welcome!

Welcome to the ConneXions Coaching experience and working together as client and coach. ConneXions wishes to share some items to facilitate a synergistic relationship with you and your coach. If you have any questions, please call us.
YOUR PREFERRED COACH
coach*
*
FEE

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

PROCEDURE
- Clients arrive for their appointment on time.
- Let the coach know what you want to work on, and be ready to be coached.
- The agenda is client generated and coach supported.
SESSIONS

Our agreement includes a set number of sessions. If you or I are on vacation, we will discuss how to accommodate both of our schedules.
CHANGES

Clients must give their coach 48 hours notice if they have to cancel or reschedule a call or session. A missed call or visit is forfeited, and you will be charged for the full amount of the call or session.

EXTRA TIME

You may call between sessions if you need “spot coaching” or have a problem. ConneXions enjoy delivering this extra level of service. 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 coach. If your coach 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 coaching is a success, it is necessary for the client to implement the coaching that is given. 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.

Coaching Agreement & Informed Consent

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

Services

The services provided by ConneXions include Coaching or TeleCoaching on topics decided jointly with you, the client. The purpose of coaching is to develop and implement strategies to help you reach personally identified goals of enhanced performance and personal satisfaction. Coaching 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 Coaching?

Coaching 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. Coaching 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 coach is a person participating in a mutually voluntary interaction with neither responsibility, accountability nor authority over the outcomes of the person being coached.

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

Life coaching is a powerful human relationship which assists people to design their future and understand their present rather than get over their past. Through a typically long-term relationship, coaches aid clients in creating visions and goals for all aspects of their lives and creating multiple strategies to support achieving those goals. Coaches recognize the brilliance of each client and their personal power to discover their own solutions when provided with support, accountability and unconditional positive regard (validation). The client can count on the coach to be honest and straightforward in asking questions and making requests.

Coaching vs. Psychotherapy

Although there are some similarities between coaching and psychotherapy, ConneXions does not conduct psychotherapy with its coaching 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 coach, 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 behavioural charges, (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. I will support, encourage, teach, and help you stay "on track" toward your goals.

Your success will depend on your willingness to define and take risks and try new approaches. You can expect me to be honest and direct asking straightforward questions and using challenging techniques to help you move forward. Like any human endeavour, coaching 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 Coaching does NOT identify, diagnose, and treat nervous and mental disorders.

Payment Procedure:
This agreement, between coach and the above-named client will begin on
Date*
Date Format: MM slash DD slash YYYY
*.
The fee for each 50-minute session is $
The fee for the initial meeting is $*
* , payable monthly in advance.
Forty-eight (48) hours advance cancellation notice is required for all face-to-face, telephone and teleconference (including Skype and ConneXions Classroom) appointments in order to avoid being charged for the time that has been set-aside for you. The Coach is paid in advance of each series of coaching calls or contacts. The first coaching session will begin after ConneXions receives this signed agreement and the first payment. You may pay by cash, credit card (Visa, MC) or check. Services must be paid for in advance, or they cannot be provided. Services requested by the Client in addition to coaching calls, will be billed at a prorated hourly rate (agreed in advance) and will be paid within 30 days of service. Any changes to this procedure must be mutually agreed upon in writing.
Call Procedure:

If the Client chooses to be coached by telephone or Skype, the Coach will call the Client at the prearranged time and telephone number as scheduled, and pays any telephone charges for the call. Your session will begin at the time agreed upon between the Coach and Client. For example: the session begins at 2pm up to 2:10pm. Be prepared at 2pm to start anywhere between that ten-minutes time frame. For group coaching calls and classes, the Coach will pay for the teleconference line, and the Clients will pay for the call into the conference line. For ConneXions Classroom meetings, the Coach will pay for the conferencing service, and Clients will pay for Internet access to join the meeting.

Cancellations:

Please remember that you must give 48 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. I will make reasonable efforts to reschedule sessions that are cancelled in a timely manner.

Termination:

Either party may end the coaching relationship by providing the other party with a one-week written notice, which may be transmitted by email, fax or in person.
Your signature below indicates that you have read the information in this document (“Coaching Agreement and Informed Consent”) and any attachments, such as the Coaching Fee Plan, and agree to abide by its terms during our professional Coaching relationship.
Client*
Client*
Country
City
Latitude
Longitude
Timezone
Continent
Date*
Date*
Date Format: MM slash DD slash YYYY
Coach*
Coach*
Date*
Date*
Date Format: MM slash DD slash YYYY

ConneXions Coaching
Teleconferencing Software Informed Consent
Having been fully informed of the risks listed below, I
Name*
*
hereby give my informed consent to use Skype and/or other teleconferencing software to facilitate coaching 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 Coach utilize such software to facilitate my coaching sessions.
Risks include but are not limited to:
1. With the use of any teleconferencing software, there is inherent risk of eavesdropping and/or accidental information disclosure. Although ConneXions Coaches 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.
2. 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.
3. 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 Coach 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.
4. 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.
5. 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 Coach 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 Coaches 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 coaching with ConneXions Classroom. I understand that the coaching relationship is different from a psychotherapeutic or counselling relationship. The psychotherapeutic relationship places the professional in a position of legal authority and power over the patient. On the other hand, the coaching 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 coaching relationship. As a coaching 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 coaching 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 Coaches 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*
Signature*
Date*
Date*
Date Format: MM slash DD slash YYYY

CONNEXIONS CLASSROOM INTAKE FORM
Date*
Date*
Date Format: MM slash DD slash YYYY
Social Security No. *
Social Security No.*
Name*
Name*
DOB*
Date of Birth*
Date Format: MM slash DD slash YYYY
Age*
Age*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone Numbers:* Daytime
Phone*
Work*
Phone*
Occupation*
Occupation*
Highest Level of Education*
Highest Level of Education*
Emergency Contact*
Emergency Contact*
Phone*
Phone*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Relationship*
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*
Date Format: MM slash DD slash YYYY

CLIENT DATA FORM
Date:*
Date*
Date Format: MM slash DD slash YYYY
Name:*
Name*
Occupation:*
Occupation*
Business Name:*
Business Name*
Home Address:*
Preferred Address
- Yes
Home Address*
Business Address:*
Preferred Address
- Yes
Business Address*
Day Phone:*
Day Phone*
Evening Phone:*
Evening Phone*
Fax Line:*
Fax Line
Cell Phone:*
Cell Phone*
E-mail Address:*
E-mail Address*
Okay to leave messages everywhere?*
- Yes
- No
If not, explain:
Preferred means of communication:*
Preferred means of communication:*
Date of Birth: *
Date of Birth:*
Date Format: MM slash DD slash YYYY
Age:*
Age*
Other Significant Dates:*
Other Significant Dates:*
Preferred Coaching Schedule: (day of week)*
Preferred Coaching Schedule: (day of week)*
[or] (time of day) *
[or] (time of day)*

: HH

MM
Names of important people in your life:*
Name (s) Relationship

Click the + icon to add more list
Other information you want us to know:*
How did you hear about our coaching services?*
What influenced your decision to work with a coach?*
Have you ever been coached?*
- 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?*
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 coaching by phone.)
Life Story*

THE FIRST STEP: DE-CLUTTERING

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

Place a value from 1-10 in each sector representing the degree of fulfillment you experience in each area.
MISSION STATEMENT OF VALUES
Spirituality*
Community Service*
Health & Fitness*
Family & Friend Relationships*
Recreation*
Finances*
Career & Job*
Personal & Intellectual Growth*
TEMPLATE FOR PERSONAL VISION STATEMENT

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 coaching and modeling for my clients, being known as an expert in my specialty, etc.)

PERSONAL VISION WORKSHEET

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.
In my personal life I am committed to*
GOALS

What goals, aspirations, desires, and intentions do you want to accomplish in the first six months of life coaching?
Business:
Personal:*
What do you want to accomplish, change, or create in the first 30 days of life coaching?
Business:*
Personal:*
What I hope to gain from this coaching relationship:*
Other things I’d like my coach to know about me:*

Name	Relationship

Name (s)	Relationship

ENERGY DRAINERS AT WORK	ENERGY DRAINERS AT HOME

Step 1 of 9 - Policies and Procedure

ConneXions Coaching

Policies and Procedure

Welcome!

YOUR PREFERRED COACH

Coaching Agreement & Informed Consent

ConneXions CoachingTeleconferencing Software Informed Consent

CONNEXIONS CLASSROOM INTAKE FORM

CLIENT DATA FORM

YOUR LIFE STORY

THE FIRST STEP: DE-CLUTTERING

BALANCING YOUR LIFE

MISSION STATEMENT OF VALUES

TEMPLATE FOR PERSONAL VISION STATEMENT

PERSONAL VISION WORKSHEET

GOALS

ConneXions Coaching
Teleconferencing Software Informed Consent