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Onboarding - Adult
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Your Contact Information
Name
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Email
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Mobile Phone
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Your Address
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What is Your Occupation
Date of Birth
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Who Referred You?
Family Member
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Name of Emergency Contact
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First
Last
Phone Number of Emergency Contact
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Mobile preferred
Your Psychiatrist's Contact Information
If applicable
Psychiatrist Name
First
Last
Psychiatrist Phone
Psychiatrist Email
Your Diagnosis
Diagnoses
ADHD
Autism Spectrum Disorder
Executive Function Disorder
Oppositional Defiant Disorder
Obsessive Compulsive Disorder
Depression
Anxiety Disorder
Sensory Integration Disorder
Dyslexia
Dyspraxia
Dyscalculia
Sleep Disorder
Substance Abuse Disorder
Binge Eating Disorder
None of These
Current Medications
You can add additional medications by using the + button at the end of the row.
Medication Name
Current Dose
Dose Frequency
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What Brings You to Coaching?
Which of the Following Traits Do You Experience?
Physical Hyperactivity
Ceaseless Mental Thoughts
Difficulty Sustaining Attention
Impulsive Actions
Making Careless Mistakes
Difficulty Organising Tasks & Activities
Avoiding Tasks Which are Boring or Require Sustained Effort
Regularly Losing Belongings
Easily Distracted & Losing Focus
Difficulty Sitting Still for Prolonged Periods
Interrupting or Speaking Over Others
Finding it Difficult to Queue
Difficulties With Sticking to a Budget
Sensitivity to Rejection
Easily Overwhelmed
Frequently Running Late
Waiting Until the Last Minute to Complete Work
Often Going to Bed Late
Finding it Hard to Disengage from Technology
Easily Irritated or Upset
Lying in Bed Ruminating on Past Mistakes or Worrying About the Future
Expecting Perfection in Certain Areas of Life
Often Feeling Too Hot or Too Cold
Hypersensitive to Noise
Difficulty With Prioritising Tasks
Other
Which Other Traits Do You Experience?
You can add additional traits by using the + button at the end of the row.
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What Are the Top Three Challenges You Are You Experiencing?
What Three Goals Would You Like to Achieve in the Next Six Months?
How Many Hours of Sleep Do You Get on Average?
How Many Times Per Week Do You Exercise on Average?
Consents & Obligations
I abide by the ICF Code of Ethics which are documented here:
https://coachingfederation.org/ethics/code-of-ethics
. All content and outcomes from our sessions are strictly confidential. In the unlikely event that I am concerned about the Coachee or a Third Party is at risk, I will discuss this with the Coachee directly, but if I am still concerned, I will discuss this with their Doctor/Parent/Partner/Emergency Contact.
I will send you a short questionnaire before each session to clarify what you would like to work on during our time together. I will do my best to reschedule appointments if requested by the Client. I will respond to emails, texts or phone calls within 24 hours unless I am away. Phone calls between sessions are free of charge if under 10 minutes in length.
Clients are Responsible for Taking Their Own Notes During Appointments. What Form of Note-Taking Works Best for You?
Handwritten Notes
Typed Notes
Using a 'Notes' App
Other
Client Obligations
(Required)
For coaching to be successful there needs to be a commitment to the sessions and to do the agreed work in between sessions. Are you willing to commit to a minimum of 5 sessions and to dedicate at least 1 hour in-between sessions to work on the agreed areas?
Appointment Conduct
(Required)
Unfortunately, humans cannot multi-task. Do you agree to attend our video calls from a stationary position, with limited background noise and distractions (eg email/text notifications turned off)?
Consent
(Required)
You confirm that you have requested coaching from Sarah Doll-Steinberg of The Mind Practice.
You confirm that you give permission for Sarah to collect and use your information to prepare for your coaching sessions and to monitor progress.
You hereby give your consent for Sarah to share your information if requested by law; with her own colleagues/supervisors for the purpose of learning and improving her services; or if someone is at risk. (Note: Sarah will not share information about clients/patients without consent unless the law or the person allows them to do so).
Sarah holds clients'/patients' data securely for the time required by law or until they request her to delete it. Your data will be stored either on Sarah's password protected computer, external hard drive, locked filing cabinet or in her Business Workplace Cloud, a highly secure, reliable and compliant environment. You agree with the way your data is stored.
Under GDPR you have the right to request access to information Sarah holds about you. To make a request for your personal information or records please email contact@themindpractice.com.
I confirm my consent
Cancellation Policy
(Required)
A minimum of 24 hours’ notice is required for cancellation/ postponement of an individual coaching session. The Mind Practice reserves the right to charge fees in full for coaching sessions cancelled / postponed with less than 24 hours’ notice. Where the requisite notice is given every reasonable effort will be made to reschedule the session as close to the originally scheduled date as practicable.
I agree to the cancellation policy
Would You Like a Copy of Your Responses Sent to You by Email?
Yes
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