Core Needs Coaching

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Core Needs Coaching

Please complete this form to submit your interest in receiving coaching. Sessions are 50 minutes long and are held virtually. The fee per session is $75 to be paid at the time of booking.

This form is used to help us assess if Core Needs Coaching is the best fit for your particular circumstances. All responses are confidential and will not be shared with anyone.

Email *

First Name *

Last Name *

Date of Birth *

YYYY

Street Address *

*This field is essential because Ike only offers coaching to those outside of a 50 mile radius of Bright City Church where he is a Pastor. This is to prevent a conflict of interest and to avoid the appearance or actuality of financial impropriety.

City *

State *

Zip Code *

Please describe your reason for seeking coaching. *

Core Needs Coaching Agreement

IKE MILLER

6216 FAYETTEVILLE RD. STE 106. DURHAM, NC 27713

IKE@IKEMILLER.COM

CORE NEEDS COACHING INFORMED CONSENT

GENERAL INFORMATION: Core Needs Coaching is a process for accessing your deepest fears, most profound wounds, and core needs. This process will exploration into your personal story and its impact upon your current relationships including marriage, parenting, friendships, and professional relationships. Coaching sessions are conducted entirely virtually.

INFORMED CONSENT: Core Needs Coaching is not professional counseling and is not designed for the diagnosis and treatment of mental health concerns. If I determine that your needs exceed the scope of coaching, I will provide an appropriate referral for a mental health professional in your area.

CORE NEEDS COACHING POLICIES & PROCEDURES

FEE SCHEDULE: Fees are $100 per 50-minute coaching session. In the event of financial need, session fees will be agreed upon between the coach and client.

PAYMENT POLICY: Payment is due in full at the booking of each session unless alternate payment arrangements have been made. Payment is to be made through Venmo or our online payment processing system.

CANCELLATION POLICY: 24-hour notice for cancellation is required for reimbursement. Without 24-hour notice, clients will be charged at full fee. If cancellation is due to illness or emergency situations, clients will not be charged.

CONFIDENTIALITY: Your treatment is confidential within the limits prescribed by law. No information about your treatment will be released without your request or written consent. However, relevant laws require that I contact others about your safety if you present a danger to yourself or others, or if I learn of child abuse or neglect. If you (client) are under 12 years of age, I must discuss parameters of your treatment with your parent(s) or legal guardian(s). If you are over 12 years of age and under 17 years of age, I may discuss your treatment with your parent(s) or legal guardian(s) with your consent. It is important that you understand that your confidentiality cannot be guaranteed if you use or request your coach to use any form of electronic communication including but not limited to email, text messaging, social networking, video conferencing, et al.

BY CLICKING THIS CHECKBOX I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

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