Reveal Yourself-Personal Coaching Intake Form

First Name

Last Name

Date of birth

Address

City

State

Email *

Mobile Phone *

Personal Coaching Question # 1 Employer Name and Address

Work Phone

Emergency Contact Name

Emergency Contact Phone Number

Have you used the Zoom Platform online? If not please be sure to install on your phone and computer, as this is the platform we will be using.

Yes

What social media platforms do you use most?

Facebook

Instagram

Twitter

If you were to create a one sentence Vision Statement for yourself what would that be

Do you have biological and/or siblings from other marriages? If so ages and where do you fit into the order?

Relationship Status

Single

Partnered

Married

Divorced or Separated

How long are you separated and/or divorced? Have you been married or divorced more than once?

Did you have children, how many, ages, girl, boy?

MINDFUL AWARENESS.......Awareness of the present moment; paying attention to what you are doing while you are doing it. On a scale of 1 (low) - 10 (high), how would you rate this area of your life currently?

DESIRED STATUS.......Improvements, changes or enhancements. What would make this area a “10” for you? *

What is the outcome you would like from this Personal Coaching and Enlightenment Program?

MOVEMENT, EXERCISE, REST.......Activities of daily living, such as mindful meditation, stretching, dancing, yoga, walking, running, cycling etc. balanced with adequate rest and relaxation. On a scale of 1 (low) - 10 (high), how would you rate this area of your life?

DESIRED STATUS.......Improvements, changes or enhancements. What would make this area a “10” for you?

NUTRITION.....Eating a balanced, healthy diet.... On a scale of 1 (low) - 10 (high), how would you rate this area of your life currently?

DESIRED STATUS.......Improvements, changes or enhancements. What would make this area a “10” for you?

RELATIONSHIPS and COMMUNICATION.... Spending time with family, friends and/or coworkers who are supportive and with whom you communicate effectively, currently. On a scale of 1 (low) - 10 (high), how would you rate this area of your life?

DESIRED STATUS......Improvements, changes or enhancements. What would make this area a “10” for you?

SPIRITUALITY.....Seeing purpose and meaning in something larger than oneself; may include religious affiliation, spiritual practice or other areas such as nature or the arts, currently.

On a scale of 1 to 10, rate the following: Relationship with Self

Connecting with Partner (if you have one)

Connecting with the opposite sex

Intimacy in Relationships

Describe your significant past relationships? (How many? how long have each lasted? why did they end?)

How many times have you been married/divorced?

Do you enjoy sex? If not, why?

Sexual Satisfaction

Have you had a sexually transmitted disease?

Yes

May Be

Have you ever experienced emotional, physical and/or sexual traumas? Please give as much detail here, as this will support you.

Do you take any medication? If so, what?

Describe your relationship with your mom when you were a child? The more details you give the deeper your healing will be.

Describe your relationship with your dad when you were a child? The more details you give the deeper your healing will be.

Describe your relationship with your mom now. The more details you give the deeper your healing will be.

Describe your relationship with your dad now. The more details you give the deeper your healing will be.

Did you write in a diary when you were a little girl?

Yes

Sometimes

Do you journal now, if yes how often?

Where was your favorite place to go as a little boy little girl?

Have you had any major physical trauma in your life? (accidents, injuries, illnesses etc)

Have you had any major emotional traumas in your life?

Any other information, which may be relevant to your sessions?

How often do you exercise?

Daily

3 times a week

Seldom

Please describe any experience you have with mindfulness or other forms of meditation.

How often do you meditate?

Daily

3 times a week

Seldom

Are you open to learning how to meditate?

Yes

Maybe

DIET: How is your appetite?

Extreme

Strong

Good

Lacking

How many meals do you generally eat each day? *

How often do you eat?

Do you... (check all that apply)

Eat out Often

Diet Frequently

Skip Meals Frequently

Do you have any special diet or eating restrictions? *

Yes

If yes, what are the restrictions?

List the primary foods you include in your diet *

List the foods you exclude from your diet at this time *

Do you have any food sensitivities/allergies that you are aware of?

Yes

If yes, what foods?

Do you currently experience food binges?

Yes

If yes, what are your triggers?

Are you currently using coffee, diet sodas, or nicotine? *

Yes

other

In general, are you an early bird or a night owl?

Early Bird

Night Owl

What is your typical wake up and bed time?

Are you happy in your job or career?

Yes

What do you do for work / career now?

What does your ultimate job or business look like? Please describe

What personal goals or declarations have you set for 2020?

What makes you happy?

Are you open to journaling?

What are your 3 top gratefulnesses currently?

What is your individual & unique purpose in this life?

What would you like to change most about your life?

What behaviors, habits, or thoughts would you like to eliminate?

Medical History - any operations, accidents, illnesses, medication Present Health and Medication you are taking

DEFINITIONS.... This is to just help clarify your understanding of the terms on the current and desired status portion of this form. Mindful Awareness: How much to you run on ‘automatic pilot’ and tend to ‘tune out’ of what’s going on around you? Practicing mindfulness means to pay more careful attention in a particular way. When we are mindful, we are aware of what’s going on outside and inside our own skin. All of our senses are alive and active and we know what is happening in this, the present moment. We allow ourselves to become more deeply and completely aware of what it is we are sensing. Movement, Exercise and Rest: Most adults should do 30 minutes of exercise, 5 days per week. To break this down further it’s suggested a minimum of 2 ½ hours a week of moderate-intensity aerobic activity (i.e. brisk walking, dancing, gardening, etc.) or 1 ¼ hours of vigorous aerobic activity (i.e. jogging, aerobic dancing, jumping rope, etc.) in episodes of at least 10 minutes, and preferably spread throughout the week. There should also be some muscle strengthening activities (pushups, weight bearing exercises, yoga, etc.). Nutrition: Developing a healthy and balanced nutritional program is a cornerstone for attaining optimal health. Traditional American diets contain excessive amounts of processed foods which contribute to the development of disease and impede the healing process. Do you take the time to find nutritious foods and cook at home? Physical Environment: The spaces we inhabit have a major impact on how we feel, physically and emotionally. Consider: The climate, urban/country, your view, your home (clean, uncluttered, comfortable, temperature good, plants, music, lighting, décor, use of healthier alternatives for cleaning products). Relationships and Communication: There is a positive correlation between positive social relationships and good health. Do you get along well with your ‘inner circle’ of family and friends without them adding additional stress to your life? Spirituality: Spirituality is at the core of your being; it is a central component of how you experience life and see the world. Spirituality frequently comes from our own experience of deep connection, meaning and purpose. This can provide a source of healing strength in the face of adversity, illness suffering or death. Personal and Professional Development: Some people have careers or daily activities (motherhood, volunteer work, creative endeavors, reading, etc.) that resonate with their purpose and values in life, while others work in jobs that have high demands with little personal or professional rewards. Sometimes there is a lack of balance across personal and professional aspects of their lives. Activities that connect us with energy, interest, satisfaction, and sheer pleasure enhance our sense of contentment and joy and ultimately to our health. These can be ‘doing’ activities or ‘being’ activities (watching the stars, watching the tide roll in, etc.). Mind-Body Connection: A growing body of evidence indicates that virtually every illness we experience is influenced, for good or bad, by our thought patterns and emotions. The more we can encourage different modes of ‘communicating’ between the mind, the brain and the body, the more we can gradually form healthier pathways for thought, behavior and health. How positively do I think about things and myself throughout the day? Professional Care – Prevention and Intervention: Do you integrate the healthcare you receive from your physicians with complementary approaches to support your health such as acupuncture, massage, nutrition counseling or weight loss programs, nutritional supplements, energy medicine, etc. Do you generally lead a healthy lifestyle – avoid tobacco, excessive alcohol and drugs, take medications as prescribed?

Coach Disclaimer of Liability Staci Michele Kessler, Reveal Yourself with Grace and Ease, llc. is /are an Ontological, Englightenment Coach, but she is not your medical doctor. She is strictly acting as a Coach and talking to you as a Coach and Educator. It is your responsibility to determine how to use the educational information learned from Staci Michele Kessler, Reveal Yourself with Grace and Ease, llc. or her associates. If you have a medical condition and need medical advice you need to contact your health care provider.When you enter into a coaching agreement with Staci Michele Kessler, Reveal Yourself with Grace and Ease, llc. you are considered a Coaching Participant (Client). Coaching Participant hereby employs the Staci Michele Kessler, Reveal Yourself with Grace and Ease, llc. and her associates (Coach) for the purpose of advising the Coaching Participant with respect to Coaching Participant’s strategic planning, communications, team leadership, and/or quality of life. “Coaching” is a Professional Coaching Participant relationship that the Coaching Participant has with the Coach, designed to facilitate the creation and development of personal, professional or business goals, and/or to develop and carry out a strategy and plan for achieving those goals. Your Coach has experience in such matters and agrees to render such coaching services. Coaching Participant understands and your Coach agrees not to be an employment agent, financial analyst, business manager, psychotherapist, psychiatrist, family or marriage counselor, be your medical doctor or any other profession of the healing arts. Staci Michele Kessler, Reveal Yourself with Grace and Ease, llc. and her associates are Coaches. Nothing more and nothing less. Your Coach cannot, and does not, make any promises, guarantees, warranties or representations about results other than Coaches diligent work with you. Services are being provided “AS IS” without warranty of any kind, either express or implied, including without limitation any warranty for information, coaching, products or services provided through or in connection with the Services. The Services are requested at the Coaching Participant’s own choice and with inherent singular responsibility of the Coaching Participant.Your coach has not promised, shall not be obligated to, and will not 1) procure or attempt to procure employment, business or sales for the Coaching Participant 2) perform accounting services, tax advising or investment counseling or 3) act as a therapist, provide psychological or psychiatric counseling or treatment, marriage or family counseling, medical treatment, or any other aspect of the healing arts.The Coaching Participant fully understands that Coaching Services are being provided with the understanding Coach is not licensed in any of these areas or even in your State. Coach has other associated professionals if needed, including State Licensed (FL) psychotherapists, accountant(s), financial advisors, and medical professionals Coach can refer Coaching Participant to if needed.Coaching Participant is utilizing any or every part of the Services entirely at Coaching Participant’s own risk. The Coach shall not be responsible for any loss or damage caused, or alleged to have been caused, directly or indirectly, by the information or ideas contained, suggested, or referenced in the Services. Coach is simply providing free speech and educational information. It is up to the Coaching Participant to decide how to use this information to improve their life. Coaching Participant’s understanding that Coaching Participant is able to make his or her own decisions about all matters in life, and the Coach is not responsible for Coaching Participant’s decision(s) or non-decision(s), whether it be personal, business, financial, health, or any other decisions or lack of, which Coaching Participant fails to make or not make.The information, instruction or advice given by Coach is not intended to be a substitute for competent professional medical or psychological (mental) diagnosis, treatment and care. Coaching Participant should not discontinue or modify any medication or therapy presently being taken pursuant to medical advice, without obtaining approval from your healthcare professional. If a Coaching Participant suspects a medical condition they should always seek medical attention from a their personal physician or find the appropriate health care professional to evaluate their complaints. As a Coaching Participant, you must take complete responsibility for your own physical health and emotional well-being.Coaching and this form/website are not a substitute for you seeking expertise from specialists in the following fields: all medical, physical and mental health specialties and conditions, psychology and psychological counseling, wellness, therapeutic interventions (including spiritual and/or religious beliefs), diagnostic procedures and screenings, any form of physical or mental health counseling or treatment, or evaluation and treatment from professionals of the healing arts. It is up to you to independently assess any decisions, actions or inactions, resulting from or relating to the website or a coaching experience.Coaching and the website are not a substitute for advice and/or representation from professionals for legal, financial, tax, personnel, personal, religious, or spiritual. It is up to you to independently assess any decisions, actions or inactions resulting from or relating to the website or a coaching experience.In general, all communications between Coaching Participant and Coach are confidential. No information about Coaching Participant will be released outside the sessions without Coaching Participant’s permission. The EXCEPTIONS to confidentiality include, but are not limited to the following: (1) the Coach determines Coaching Participant is a threat to himself or herself, or another person; (2) there is suspected abuse or neglect of a child, an elderly or disabled person; (3) Coaching Participant is threatening to commit a crime; (4) there is a medical emergency; or (5) through a court order to disclose Coaching Participant’s records. In the event of such a situation, Coach will make reasonable efforts to discuss it with Coaching Participant before taking any action. Moreover, Coach may disclose any information from coaching sessions as required by applicable law as necessary or advisable to: (a) protect Coach’s rights, safety or property or the rights, safety or property of others; (b) enforce the Terms of Use and/or this agreement, including consultation(s) with counsel; (c) respond to your requests for customer service or other information; (d) comply with legal process or cooperate with law enforcement or governmental requests; or (e) comply with or as permitted by applicable laws and regulations.Coaching Participant hereby waives any and all claims against the Coach, its staff, directors, officers, employees, associates, subcontractors, volunteers, agents, and other members that relate to coaching services or the consequences that may occur as a result of following the advice given. Any disputes that may arise between Coaching Participant and the Coach shall be resolved by mediation, and if not resolved by mediation, then by binding arbitration under the procedures and supervision of the American Arbitration Association. Damages will be actual monetary damages only. The prevailing party will be entitled to attorney’s fees. Jurisdiction for any action shall be West Palm Beach, FL.Coaching does not involve the diagnosis or treatment of physical or mental disorders as defined by the American Medical Association, American Psychiatric Association, Medicare and Medicaid. Coaching is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment. Coaching is not to be used in place of any form of diagnosis, treatment or therapy. Coaching is not to be used as a substitute for professional advice by legal, medical, financial, business, spiritual or other qualified professionals.All decisions in these areas are exclusively the Coaching Participant’s and the Coaching Participant’s decisions and actions regarding them are the Coaching Participant’s sole responsibility. The Coaching Participant is fully responsible for the Coaching Participant’s physical, mental and emotional well-being during the coaching calls, including the Coaching Participant’s choices and decisions.You must agree to hold harmless Staci Michele Kessler, Reveal Yourself with Grace and Ease, llc. (Coach) and anyone affiliated with Staci Michele Kessler, Reveal Yourself with Grace and Ease, llc.from any claims, liability, or loss incurred directly or indirectly by you (or anyone you may teach or seek to help using) as a result of the use or application of any techniques or methods learned from the Coaching sessions. 6) Please note, there will be no refunds once you have had your first session and/or this agreement is signed.

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