Intake Forms 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.Coaching vs. CounselingThis 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 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.Name(Required) First Last Date(Required) MM slash DD slash YYYY Intake FormName(Required) First Last Email(Required) Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Best Time to Call Is it ok to leave a message at all phone numbers and email? If not please specify:Occupation Name of Business How long at this employment? Are you happy at this employment? If no, please tell me briefly what you would like to be doing differently?Date of Birth: Age: Emergency Contact: Name and relationships of important people in your life (spouse, partner, children, friends) Add RemoveDo you have any pets, if so, what are their names? Add RemoveEducation History:PrimarySecondaryTertiary Add RemoveHealth Status: Do you have any difficulty with sleep? If yes please explain:Are you happy with your current weight and body shape? If no, please briefly tell why?Do you have any history with drugs or alcohol? If yes please describe:Are you currently seeing a therapist? 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 briefly describe the reason for seeing a therapist.Do you take any medications? If yes what?Do you exercise regularly? If yes, what type of exercise and how frequently?How many hours of television do you watch daily?What do you enjoy doing on your free time?Is there a secret passion in your life? If yes, what is it?Do you have a higher purpose? If yes, briefly describe:If you knew you could not fail, what would you attempt to do?Agreement to Coaching ProcessPlease 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.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.(Required) 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