Intake Form

Preferred Name

Pronouns

Preferred Relationship Dynamic

Email

Okay to Email this address?

Yes

No

Phone

Okay to Call or Text this number?

Yes

No

Time Zone and Availability

Have you had any previous coaching?

Provide a description of your situation

Are you currently suffering from any physical or emotional symptoms related to traumatic experience?

Yes

No

In order to move forward, please read and understand each of the following items and check them off:

Agree that coaching isn't psychotherapy

I understand coaching is not psychotherapy or medical treatment. I understand that it is recommended to have additional avenues of support, such as a psychotherapist, when pursuing deep inner work.

Agree with drugs and alcohol message

I understand drugs and alcohol are not compatible with coaching and anything else we may do in the process of working together.

I waive liability

I am voluntarily participating in the Personal Coaching services provided by Leanne and/or Greg Million of Calgary, Alberta, Canada and that as a participant, I agree to waive my right to hold them liable or responsible for any and all personal injury or financial or property damages incurred by myself or others now or in the future that may be directly or indirectly related to my participation as a coaching client.

I take responsibility for my choices

I take full and complete responsibility for my choices and actions both during and following all coaching and will not hold Leanne and/or Greg Million personally or professionally liable for any negative outcomes.

Legal release agreement

Coaching certification is not granted by a medical or psychological certifying body nor is it conducted by medically or psychologically trained professionals. I have assessed my own ability and I declare myself capable of making my own decisions, being of sound mind. If this is later disputed by any other party, I hereby release Leanne and/or Greg Million of any and all legal responsibilities now and in the future as they are not aware of any reason why I may not make my own legal decisions. I also have not declared to them any medical reason why I may not safely participate in the coaching programme provided by Leanne and/or Greg Million.

I understand the risks

While every effort will be made by Leanne and/or Greg Million to keep written records confidential, I assume the risk that they may be accessed by a third party and waive my right to hold Leanne and/or Greg Million liable for any damages related to the disclosure of such information by a third party.

I understand the technology required

I am aware that to facilitate online sessions, online applications and programmes must be utilized that may include but are not limited to Zoom, FaceTime and Messenger. I will personally assess the technology used for contact, and by agreeing to the use of any online technology assume all and all risk of the conversation potentially being illegally accessed, monitored or recorded by a third party. I hereby waive any right to pursue compensation for such a violation and recognize that I am assuming the risk posed by using phone, email, text, messenger, and any video conferencing technology.

I've read the above and agree to them

Waiver: I have read, understand and agree to the above statements. I acknowledge and accept all the terms outlined in this waiver. I hereby waive Leanne and/or Greg Million of any and all liability, past, present or future, relating to our work together.

I agree to all of the above

Yes

No

Finally, how did you hear about me? Finally, how did you hear about me?

Captcha

Leanne Million B.F.A., B.Ed.

Certified Life, Relationship, and Sexuality Coach

EMPOWERED POLY Coaching Services

In order to move forward, please read and understand each of the following items and check them off:

Let’s get started!

Location & Time Zone

Follow

Email