Client Intake & Release Form: Many Ways, LLC.

I look forward to working with you. We will use our session time for discussion, so there is no need to belabor your answers here. Your responses help me prepare a space for you, while collecting basic information and consent. If you have any additional questions or concerns, please email: amelia@manywaysforward.com

First name

Last name

Phone

Preferred Pronouns

Age

How did you hear about Amelia Psmythe Seger and Many Ways?

What is currently going on in your life, work, or body, that you would like to shift? Please briefly note any stressors, patterns, dynamics, or physical symptoms that stand out and how they impact your life

What goals or hopes do you have for our work together?

Are you currently working with a therapist and/or have an emotional support network? Please briefly describe.

Do you have a mental health or other health diagnosis I should know about? If so, please let me know what you're holding and how I may best support you.

Is there anything else you would like me to know?

RELATED TO PRIVACY: While Amelia is not a licensed provider, and is not subject to HIPAA, she complies with the spirit and ethics of those guidelines to the maximum degree she is allowed by law. Your personal information and Amelia’s notes will be kept confidential, and your information will not be shared or forwarded unless authorized by you or required by a court. Similarly, Amelia is not a mandatory reporter, but would honor those guidelines, and address those issues with you.

RELATED TO DOCUMENTING COACHING SESSIONS: Amelia is in the process of certifying with the International Coaching Federation. As such, she needs to log and count client hours, documenting name, contact information, and total hours of the engagement.

I consent for Amelia to document our session hours towards ICF-accreditation.

I DO NOT consent for Amelia to document our session hours towards accreditation.

RELATED TO PAYMENT: All payments are due upon registration. Payment links are provided within this site, or other options are available upon request (venmo, paypal, bank transfer, etc)

RELATED TO CANCELLATIONS: Individual sessions are reserved exclusively for you. If you are unable to keep your appointment or need to reschedule, please notify Amelia by phone or e-mail at least 24 hours in advance. Cancellations with less than 24-hour notice will be charged a $50 cancellation fee, with the balance paid applied to future credit.

RELATED TO INFORMED CONSENT & RELEASE OF LIABILITY: ***By completing and signing this form, you are giving your consent to work with Amelia, and acknowledging liability rests with you.***

Please confirm that you have read this and understand.

Signature

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