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Intake Forms

Jillian Smith M.A

619-261-6189

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.

Coaching vs. Counseling

This document outlines the differences between Coaching and Counseling, ensuring you understand which service is right for you before beginning our work together.

By signing below, you acknowledge that you understand the key differences between Coaching and Counseling and that you are choosing Coaching for your needs.

Coaching vs. Counseling Acknowledgement

My 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.
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Intake Form

Name(Required)
Address
Name and relationships of important people in your life (spouse, partner, children, friends)
 
Do you have any pets, if so, what are their names?
 
Education History:
Primary
Secondary
Tertiary
 
Are you currently seeing a therapist?
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.

Agreement to Coaching Process

Please sign your name and date below as a digital signature acknowledging the following agreement: I understand that I am a client for a coaching program, not for therapy.
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Fee Agreement Acknowledgement

In 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.
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24 Hour Cancellation Policy Acknowledgement

If 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.
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Office
1150 W 11th Ave, Eugene, OR 97402
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Disclaimer

As a life coach, I provide services to help people reach their ultimate potential. I am not a licensed therapist or counselor. I don’t assess, diagnose, or treat mental, emotional, or behavioral disorders. I don’t apply mental health counseling or other psychotherapeutic principles and methods in my work. Instead, I focus on helping people get from where they are to where they want to be.


I am not a licensed psychologist in Oregon, I don’t practice psychology as that is defined under Oregon law and I don’t represent myself to be a psychologist.” In addition, my coaching services are not professional counseling services, as defined by Oregon law. I don’t represent myself to be a licensed professional counselor. Nothing on my website, in my marketing materials, in client appointments, or in communications with anyone is meant to say that I provide services for which Oregon requires a license.


Neither of these licenses is necessary for me to provide my clients with the tools to become who they want to be. If I believe it is appropriate for you to see a licensed psychologist or counselor, to supplement our work, I will make a referral.

Copyright © 2025 Life Coach – Jillian Smith M.A. – Destiny Unbound Coaching | Eugene Life Coach.

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