COACHING CLIENT INTAKE FORM
Your Name (required)
Your Email (required)
Please describe what you'd like to address here
Terms and conditions: CANCELATIONS: You must notify us a minimum of 24 hours in advance if your booking needs to change. Cancelations under 24 hours or missed appointments will be charged a 50% cancelation fee. All our appointments come with a 100% money back guarantee. If you feel that your appointment did not benefit you please let us know during your appointment and we will refund your payment. PRIVACY: All interactions with Chantal Heide Coaching, including scheduling of or attendance at appointments, the content of your sessions, progress in counseling, and your records are confidential. You may request in writing that Chantal Heide release specific information about your counseling to persons you designate.
EXCEPTIONS TO CONFIDENTIALITY:
• If there is evidence of clear and imminent danger of harm to self and/or others, Chantal Heide is legally required to report this information to the authorities responsible for ensuring safety.
• If Chantal Heide learns of, or strongly suspects, physical or sexual abuse or neglect of any person under 18 years of age she must report this information to child protection services.
• A court order, issued by a judge, may require Chantal Heide to release information contained in records and/or testify in a court hearing.
We appreciate prompt arrival for appointments. Please notify us if you will be late. Twenty-four hour notice of cancellation allows us to use the time for others.
I have read the above information and understand the nature and limits of confidentiality, and what is expected of me as a client of Chantal Heide. CHECK HERE TO CONFIRM YOU HAVE READ THE ABOVE TERMS AND CONDITIONS