Intake & Consent Form

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Before your first session with Karina Mirsky, MA, please fill out this form:

This takes 3-4 minutes to complete
Please submit at the time of scheduling, at least 48 hours before your 1ST appointment

IMPORTANT: Please also whitelist: karina.ayn.mirsky@gmail.com
(Check your Spam and Promotions folders for communications from this address.)

Email *

First & Last Name - (feel free to add a nickname, or the name you prefer to be addressed by) *

Phone *

Preferred Pronoun

She/her

He/him

They/them

Other:

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Birthdate

YYYY

Who were you referred by? *

I am seeking to work with Karina PRIMARILY for: *

Integrative Holistic Coaching (whatever is most needed)

Parts Work (IFS style therapy)

Yoga Therapy: (pain management, meditation, breathwork, relaxation)

Couples Coaching (partner sessions)

Supervision for Yoga Teachers & Coaches

Other:

I seek support PRIMARILY for: *

Managing Emotions (grief, anger, anxiety, depression)

Lifestyle Support (insomnia, burnout, overwhelm, fatigue)

Self-Awareness, Self-Development, Personal Empowerment

Love, Sex, or Relationship Issues

Physical Health Challenge (pain, injury, illness)

Spiritual Practice & Education

Other:

Are you currently being treated for or managing any significant physical or psychological health condition?

Are you taking any medications that might be useful for Karina to know about? (hormones, blood-pressure, antidepressants, sleeping pills, etc)

Is there anything else you would like Karina to know at this time? (optional)

What is your preferred method of payment? *

Credit or Debit Card (through website)

Cash or check (local clients only)

Venmo

CashApp

PayPal

PAYMENT POLICIES: By checking the boxes below you are confirming that you understand and consent to policies for payments *

Karina is not a licensed LPC or LSW & can NOT bill insurance companies.

Sliding scale discounts must be agreed to prior to scheduling.

Packages must be scheduled in full within five months

Tele-Coaching payments are due 48 hours prior to my appointment.

In-Person payments are due at the end of the session.

There is a 48 hour cancellation policy If there is a need to cancel within 48 hours, I will make a donation of at least 50% of the session fee to stay in good standing for rescheduling

Required

COACHING RELATIONSHIP AGREEMENT: By checking the boxes below you agree to enter into a coaching relationship with Karina: *

I understand that the best way to contact Karina is via email

I am committed to showing up for my scheduled appointments on time

I may request follow-up calls for emergency situations via email, and Karina will do her best to accommodate.

I understand that Karina is an international educator and may not be available some weeks or months during the year

I understand that Karina is committed to anti-discrimination & anti-racism and welcomes feedback on how to be a better ally to POC, LGBTQ+, and Differently Abled people

Required

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