Client Registration Form -Individual Sessions & Experiences - WTMG
Please fill in your details as openly and honestly as you can. This form remains confidential between you and I. Completion of the form, helps us both to prepare for the initial session in advance. The form is only required for initial sessions or when returning to services after a break in sessions. If information about your circumstances changes, please notify JK asap. You are encouraged to answer all questions applicable, openly and reflectively on your current circumstances. If you are unsure of any of the answers, please mark with 'unsure' - this helps to identify how I can support you further through coaching.
First Name
Last Name
Preferred Name and/or Pronoun
Email
Phone Number
Address
Occupation
Emergency Contact: PLEASE INCLUDE YOUR EMERGENCY CONTACTS NAME, TELEPHONE AND RELATIONSHIP TO YOU. (This is someone I could contact, in the event of an absolute emergency)
What are your expectations of the session?
250
How happy are you with your life and career overall, at the moment?
Please outline the problem/issue or goal you would like to explore through coaching together?
What do you think needs to change/evolve/Be different?
How will things be different when they've changed/evolved?
What stops you changing it/ what challenges it/makes it worse?
What do you feel you need help with most, to achieve these changes?
Are you /have you accessed any other support, therapy or guidance about this issue? If so what? What was useful? What wasn't?
Any health/medical issues (Current or Historical) that I should be aware of? (Please bring any medication with you to sessions that you may need)
Please share with me if any of the following apply to you, this does not necessarily prevent you from accessing sessions. An extra, free of judgment conversation, may be required; to ensure you receive the 'best fit' support for your circumstances.
Criminal Conviction/Offending - present or spent
Received care under mental health act professional services (Hospital/Psychiatric/CMHT) Adult/Child
Have experienced a traumatic head injury
Current experience of/Dependency/Addiction of drug or alcohol (including prescription drugs)
Issues with other addictions ( such as gambling)
Single or Multiple Trauma - Including Post Traumatic Stress (Civic or Combat)
Have been a victim of an - alleged - criminal offense (with a court case pending)
Are in the position of significant, financial concerns or debt management
Veteran - including both post-combat and non-combat roles
Other significant - life event (Please detail in other information section below)
None of the above apply to me.
Learning Needs/Style & Accessibility - Please include any info about your learning needs/style; Such as neurodiversity/Mental health ( formal or self-identified) This could include accessibility needs relating to disability/long term health condition
Describe your ideal life: Dreams/Hopes/Aspirations and Intentions? ( work/life and/or both)
Hobbies and Interests
What is your proudest moment/experience in life?
Any other information you would like to tell me?
Any questions you would like me to answer in advance of the session?
Describe your current relationship with Nature in three words!
Health & Safety considerations - please tick any that are true to you to help plan the session
Fear/Phobia of dogs or insects?
I have an allergy to something in nature ( e.g bees/wasps/plants/hayfever)
I am not very mobile on my feet or require an accessible route for wheel chair or mobility equipment
I have limited fitness and would be unable to walk 20-min
I do not drive/have access to a car
I don't feel confident in the outdoors/nature
None of the above
I am aware this session will be in nature, and I require suitable clothing and footwear for the session (including changeable weather)
Please tick the service this form relates to
Coaching Package 1:1
Personal Compass Experience
Bespoke Retreat Coaching Session(s)
Other- not listed
I would love to subscribe to the Where the Mind Grows mailing list and receive the newsletter.
I have reviewed and understand the coaching agreement
The information provided on this form is accurate to my knowledge
By completing this form I understand that Where the Mind Grows, will store and retain by data for the sole purpose of coaching provisions and am giving my consent for this.
Submit