Coaching Agreement

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Coaching Agreement

Please fill out the following information prior to your appointment with GMH Coaching.
All fields are required. Please answer N/A in fields that do not apply. (*Please note: this digital form has been created and and is stored within Google Workspace for Good Mental Health LLC which is a HIPAA compliant and secure platform*)

Client Name *

Date of Birth *

YYYY

Address *

City *

State *

Zip Code *

Phone/Cell# *

Email *

Emergency Contact Person *

Emergency Contact Relationship to Client *

Emergency Contact Phone/Cell# *

Reason for Seeking Coaching Services *

How Were You Referred? *

Do you consent to receive: *

Phone Calls

Emails

Text Messages

All the above

Required

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