Grief Coaching Intake Form Jillian Smith M.A619-261-6189 My coaching philosophy empowers individuals to navigate their grief by setting and achieving personal goals. I focus on practical strategies that foster resilience and promote personal growth. Master of Arts Marriage and Family Therapy Alliant International University, San Diego, California 2008 Bachelor of Science, Psychology and Social Science Dowling College, Oakdale, New York 2003 INELDA- International End Of Life Doula Association INELDA End-Of-Life Training Class - 33 Hours, September 26, 2021 Chapter 4 “Individuals Seeking Non 12-Step Recovery.” T. Horvath, T, Ph.D., ABPP and J. Sokoloff, MFT. Registered Intern (2010). Alcoholism & Substance Abuse in Diverse Populations The coaching fee is $500, billed monthly. Please note that payments are not set up as recurring transactions; each month will require a manual payment.Grief Coaching vs. Grief CounselingThis document outlines the differences between Grief Coaching and Grief Counseling, ensuring you understand which service is right for you before beginning our work together. Grief Coaching is a forward-focused process aimed at helping individuals rebuild their lives after a loss. It focuses on: ● Creating actionable steps to move forward and find a new sense of purpose. ● Developing strategies for coping with grief while managing life’s responsibilities. ● Setting future goals to reclaim control over your life after loss. ● Building a support system and developing new habits for emotional well-being. This approach is typically shorter-term, focusing on practical solutions and personal growth. Grief Counseling, on the other hand, is more therapeutic and focused on healing emotional wounds. It involves: ● Providing a safe space to explore intense emotions related to loss. ● Addressing the psychological and emotional impact of grief. ● Offering long-term support as individuals process their grief at their own pace. ● Helping individuals navigate complex emotions such as anger, guilt, and sadness. This approach tends to be longer-term, emphasizing emotional processing and healing. By signing below, you acknowledge that you understand the key differences between Grief Coaching and Grief Counseling and that you are choosing Grief Coaching for your needs. This document outlines the differences between Grief Coaching and Grief Counseling, ensuring you understand which service is right for you before beginning our work together. Grief Coaching vs. Grief Counseling AcknowledgementMy full name and date on this information means that I understand and accept that I am a client for a coaching program, not for therapy.(Required) Date MM slash DD slash YYYY Grief Intake FormName(Required) First Last Email(Required) Phone(Required)Is it ok to leave a message at all phone numbers and email?(Required)YesNoIf not, please specify: Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Gender(Required) Date of Birth(Required) MM slash DD slash YYYY Emergency Contact Name(Required) First Last Emergency Contact Phone Number(Required)Impact of GriefHow is your grief affecting your daily life (e.g., work, relationships, self-care)?(Required)Have you previously sought support for your grief (e.g., counseling, support groups)? If yes, please elaborate:(Required)Goals for CoachingWhat do you hope to achieve through grief coaching?(Required)Which specific areas of your life would you like to focus on?(Required)What challenges do you anticipate facing in this process?(Required)Support SystemDo you have a support system (e.g., friends, family, community)?(Required)How effective has the support been since your loss?(Required)Coping StrategiesHow are you currently managing your grief (e.g., activities, self-care practices)?(Required)Are there any coping mechanisms that concern you (e.g., substance use, isolation)?(Required)Expectations from CoachingWhat type of support do you expect from a grief coach (e.g., guidance, accountability, practical steps)?(Required)Health and Well-beingHow would you rate your overall mental and physical health?(Required) Excellent Good Fair Poor Are you currently seeing a healthcare professional (therapist, doctor)?(Required) Yes No Important: If you are currently working with a therapist, please note that grief coaching is not appropriate at this time. Our policy is to avoid overlapping with ongoing therapy to ensure you receive the most suitable support for your needs. We encourage you to continue your therapeutic work, and you’re welcome to reach out for grief coaching once your therapy concludes.If yes, please provide details:Are you taking any medications?(Required) Yes No If yes, please list:Education on GriefAs part of our coaching process, we will include education on the grief process. This will help you understand the stages of grief and coping strategies, empowering you to navigate your journey effectively. Are there specific topics or questions about the grief process that you want to explore?(Required)Emotional Well-being ScaleOn a scale of 1 (Completely Overwhelmed) to 10 (In Control), how would you rate your current emotional state?What has been the hardest part of your grief experience so far?What strengths do you bring to this coaching journey?Agreement to Grief Coaching ProcessPlease sign your name and date below as a digital signature acknowledging the following agreement: I understand that grief coaching is a partnership focused on personal growth and moving forward. I acknowledge that this includes education on the grief process and is not a substitute for professional counseling or mental health treatment. I commit to actively participating in the coaching process.Name(Required) First Last Date(Required) MM slash DD slash YYYY Fee Agreement AcknowledgementIn consideration of professional services rendered, I the undersigned, do hereby agree to the following payment arrangement with Jillian Smith M.A., I am responsible for a fee of $500.00 per month, $125.00 per hour. Electronic forms of payment are accepted. Payments are due monthly. I understand that I am solely responsible for the agreed upon fee. The coaching fee is $500, billed monthly. Please note that payments are not set up as recurring transactions; each month will require a manual payment. Not recurring payments. My full name and date on this information means that I understand and accept that I acknowledge and accept the fee agreement.(Required) Date(Required) MM slash DD slash YYYY 24 Hour Cancellation Policy AcknowledgementIf you are unable to attend an appointment, we request that you provide at least 24 hours advanced notice to our office. Since we are unable to use this time for another client, please note that you will be billed for the entire cost of your scheduled appointment if it is not timely canceled, unless such cancellation is due to illness or an emergency. For cancellations made with less than 24-hour notice (unless due to illness or an emergency) or a scheduled appointment that is completely missed, you will be mailed a bill directly for the full session fee. We appreciate your help in keeping the office schedule running timely and efficiently. My full name and date on this information means that I understand and accept that I acknowledge and accept the 24 Hour Cancellation Policy.(Required) Date(Required) MM slash DD slash YYYY