Today's Date
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MM
DD
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Name
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First Name
Last Name
Email
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Phone
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(###)
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City, State
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What is the best way to contact you?
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Text
Phone Call
Email
What area(s) are you needing support in this season:
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Check all that apply:
Emotional Awareness
Relational Connectedness
Spiritual Direction
Other
What is going on in your life where having support could be helpful for you?
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What are you expecting from our time together?
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I am open to:
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(Check all that apply. If agree to all listed check bottom box - All The Above
Godly Wisdom / Perspective
Relational Development
Psychological / Neuroscience Findings
Emotional Regulation Tools
Exercises to Support My Growth
Books / Other Resources
Challenge / Confrontation
All The Above
How can we best support you? Check all that apply
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Check all that apply
1:1 work together
Peer Group Growth
Spiritual Direction
Marriage Support
Transition & Change Support (Grieving losses)
What area(s) of life needs immediate attention:
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(Ck. all that apply)
Physical Health
Emotional Health
Relational Health
Spiritual Health
Financial Health
Career / Calling Health
All of the Above
How would you rate your physical health:
Feeling healthy for the most part.
I've been better.
Not well for multiple reasons.
Have you seen counselor, coach, therapist, or pastor before?
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If yes ... Briefly share how your experience(s) was?
PAUSE: Take a breath or two ... now, identify some of what you are experiencing currently:
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Check all that apply.
Anxiety
Anger
Abuse: Verbal
Abuse: Sexual
Abuse: Emotional
Compulsive Thoughts
Addictions: Chemical, Alcohol, or Sexual
Addictions: Gambling, Other
Controlling behaviors
Family History of Mental Illness
Eating Issues
Fear
Grief (Experienced a lot of Loss)
Hopeful Future
Insomnia / Trouble Sleeping Well
Joy
Lustful Thoughts
Meaningful Friendships
Obsessive Thoughts
Rejection
Shame or Guilt
Suicidal Thoughts
Unforgiveness / Bitterness
Workaholic
Other Issues Not Listed
EXPECTATIONS & AGREEMENT
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To become familiar with consulting, leadership development, pastoral care ministry, or coaching services, please read through the following descriptions and guidelines. All of these services will be referred at coaching (the word that combines them all together) throughout the agreement.
Section 1 - What is Coaching?
Please read the following. At the end of this entire section you will be asked to communicate your understanding of, and agreement to, these guidelines and procedures.
● Coaching is an ongoing professional relationship that helps people produce extraordinary results in their personal lives, careers, businesses, or organizations (as stated by the International Coach Federation).
● Through the process of coaching, clients deepen an understanding of themselves, develop an understanding of new concepts, gain tools for personal development, improve their performance and better their quality of life.
● In each session, the client can choose the focus of conversation while the coach listens and contributes observations and questions. The coach may bring up things to support the focus and enhance the growth. This interaction creates clarity, develops a partnership in the process, and moves the client into action.
● Coaching is meant to promote the client’s progress by providing direction, focus and empowerment. Coaching concentrates on where clients are now, identifies any barriers keeping them stuck and provides a path toward their desired future. Coaches recognize that results depend on client’s intentions, choices, and actions, supported by the coach’s guidance and application of the process.
What to Expect:
Your coach will bring their own experiences, certain tools for growth, strengths, and hope to the coaching relationship. During the coaching process, coaches are committed to providing a supportive environment for growth - providing a safe presence, encouragement, reality, challenge, and structure. Coaching will focus on where you are now and the development of your growth. The desire is to help you become the hero of your story and support you on the journey.
Client Expectations:
Coaching clients will be empowered to evaluate their progress and to bring their needs and hopes to the coaching relationship. Furthermore, in the event that a client concludes there are no longer benefits from receiving coaching services, it is asked that the client contacts the coach directly in order to supportively find the best conclusion and to provide feedback if agreed and requested.
How Coaching Differs from Clinical Counseling:
Psychotherapy and clinical counseling are health care services, while coaching / ministry does not qualify for this category. The primary focus of health care services is to identify, diagnose, and treat nervous and mental disorders. Coaching is not a healthcare service, nor does Doug Lake claim to be providing clinical counseling services. While a coach may hold a degree, certifications, or licenses, this does not correlate to the provision of counseling services during coaching / ministry sessions.
Section 2 - Outline of Client Agreement
Please read the following. At the end of this entire section you will be asked to communicate your understanding of, and agreement to, these guidelines and procedures.
Coaching Intent, Client responsibility, and Limitations of Coaching Services
1. Client Responsibility - As a client, I understand and agree that I am fully responsible for my physical, mental, and emotional well-being during my coaching sessions, including my choices and decisions. I am aware that I can choose to discontinue coaching at any time.
2. Coaching Purpose - I understand that coaching is a professional relationship I have with my coach. I understand this coaching relationship is intended to aid me in my personal and professional development by setting goals and defining steps to achieve these goals.
3. Coaching Topics - I understand that for best results, my coach may ask about and discuss varying aspects of my personal, professional, emotional, physical, financial, spiritual, and social life. I acknowledge that I am responsible to set limits as I desire in response to these topics of discussion, and I accept responsibility for implementing new choices and behaviors that might be suggested by my coach.
4. Coaching is not Mental Health Care - I understand that coaching does not involve the diagnosis or treatment of mental disorders/issues as defined by the American Psychiatric Association. I understand that coaching is not a substitute for any form of counseling/therapy, including the following: psychotherapy, psychoanalysis, mental health care, addiction treatment, and substance abuse treatment.
5. Coaching is not Meant to Replace Other Professional Aid - I understand that coaching is not to be used as a substitute for professional advice by legal, medical, financial, business, spiritual, or other qualified professionals. I commit to seeking advice in these forms from qualified professionals when needed.
6. Confidentiality - I understand that information shared in coaching sessions will be held confidential by my coach unless I state otherwise in writing. I understand that confidentiality may have to be broken as required by law. I understand that certain topics I disclose may be anonymously/hypothetically shared with other coaching professionals for training or consultation purposes. All information about the coach / client relationship will remain strictly confidential except in very rare circumstances where decreed by law; ie. where the court might issue a subpoena for the file or information.
The client also agrees to disclose details of the past or present psychological or psychiatric treatment. In entering into the coaching relationship and signing the agreement, you are agreeing that if any mental health difficulties arise during the course of the coaching relationship, you will notify me immediately so that I can discuss with you appropriate steps and if any additional referrals are needed.
7. Prior History - The client can, at any point in the coaching session, declare his/her preference not to discuss a specific issue, by simply stating that they would rather not discuss this issue. The coach agrees to respect this boundary and will not attempt to forward the conversation further along those lines.
Section 3 - Outline of Consulting Services
Please read the following. At the end of this entire section you will be asked to communicate your understanding of, and agreement to, these guidelines and procedures.
Procedures Regarding Services
1. Specifics of Sessions - After our initial call and discussion, you will be emailed the payment price sheet and payment instructions for your sessions. Payment for each session (single session or the starting session of a pack of four) is due prior to the coaching session. The first four sessions are expected to be used within 2 months of booking for maximum results (*Special Circumstances can be discussed). Please advise with any questions.
Your first appointment date will be scheduled in our call or via email after.
2. Virtual Platform - Consulting sessions are conducted via Zoom, unless otherwise stated. You will receive a link when you schedule your session via email.
3. Cancellations - Cancellations need to be made 24 hours in advance, if possible. Session canceled in less than 24 hours time, as well as missed sessions, are charged as a standing session.
4. Between Sessions - If you wish to connect in between sessions, you will be able to reach your coach via email. Your coach will respond within 24 hours. At times, your coach may provide brief coaching call (less than 10 minutes) in order to help provide support to clients as they take action steps and to solve barriers to growth.
5. Open Communication - Please practice assertive communication. Your needs matter as well as mine. Any reactions or coach’s attention so that it can be resolved as soon as possible.
I understand that I am choosing to enter into a coaching relationship with Doug Lake, which is different from a therapeutic counseling relationship. I understand the difference between the two types of services (as outlined in Section 1). I understand that I am not signing a contract to be a counseling patient. I understand that by signing this form, I will be a coaching client as outlined and described throughout this agreement. Therefore, this professional coaching work and the coaching relationship is not a counseling relationship.
New Day Leadership Consulting | douglasmlake@gmail.com
You will be contacted as to where and when our sessions will be held within 24/48 hours of receiving your intake form. Thank you!
Choose One
I have questions
I Understand Expectations & Agreement
I have read, I understand, and I agree to follow the agreement above.
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