Your Nurse Health Coach

Intake Form

First Name

Last Name

Address

Street Address

City

State

Country

Postal Code

Home Phone Number *

Email (for communication and mailing list) *

Work Number (Optional)

Cell Number

Religious Preference (Optional)

Local Congregation (Optional)

If married, years married

Spouse's Name

Name/Ages of Children (Optional)

EDUCATION High School Diploma

Yes

If no, highest grade completed

Name of College

Degree(s)

Graduate School Name

Area of Study

Business/Technical School

Did you have any learning disabilities in school?

Yes

Specify

OCCUPATIONAL INFORMATION Employer (Optional)

Length of Employment (Optional)

Type of work you do

MILITARY Have you served in the US Armed Forces?

Yes

Which branch of service?

When did you serve?

Where?

Were youdeployed during wartime or in a warlike situation?

Yes

Explain:

Have any of your family members served in the military?

CRIMINAL HISTORY: Date and Reason (Optional)

PHYSICAL INFORMATION List current illness(es) or symptoms

List any major surgeries, serious crises, losses, or handicaps (with dates)

Last medical exam

Reason

Name and Address of Physician

Current Medications

FAMILY HISTORY (please include yourself in this and specify whom it is in your family):

Are your parents divorced?

Yes

Option 3

How old were you when they divorced?

Alcoholism/Drug Abuse:

Depression, Bipolar Depression, Schizophrenia:

Other Mental Illness:

Emotional or Verbal abuse:

Coaching Counseling History. Have you ever received psychotherapy, counseling, coaching or other treatment for personal, marital, or family problems?

Yes

Dates

Name of Professional(Dr., Agency, Pastor, etc.)

Was the counseling helpful and how?

Have you had thoughts of harming yourself or ending your life?

If yes, please describe (how long ago?; did you have a plan?):

Have you had thoughts of harming someone else?

Him

Her

If yes, please explain:

Have you or any member of your family ever received or considered seeking help for drug or alcohol dependency?

Yes

Name of Professional/Agency

Substances Used

How did you hear about Your Nurse Health Coach?

Person Responsible for Payment

What results would you like to see as a result of Coaching?

Telemedicine Informed Consent

Enter your name:

hereby consent to engage in teletherapy with my existing

therapist at Your Nurse Health Coach PLLC. I understand that “teletherapy” includes the practice of mental health care

delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or

data communications. I understand that teletherapy also involves the communication of my medical/mental

information, both orally and visually, to Your Nurse Health Coach, PLC, via the teletherapy service, zoom, google meet,

or other platforms (a HIPAA compliant video platform service).

Signature*

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NURSE COACH

I will listen with full presence to the client’s topic/s in a safe, supportive environment (in person, office, Telehealth)

to increase trust and self-exploration of health and wellness goals.

I will respect the client as the authority for her/his on own health and wellbeing.

I will support the client’s inner wisdom, intuition, and innate ability for what is best.

I will involve the client in formulating SMART goals (Specific, Measurable, Action-oriented, Realistic, and Time-

lined) towards discovery, insight, creativity, and commitment to action.

I will obtain the client’s consent to coach in sensitive areas and will maintain confidentiality.

With permission, I will offer advice and health education for specific health conditions (acute/chronic), nutrition,

exercise, stress management, and other areas.

I will recommend other healthcare professionals when I feel issues are outside my scope of practice and

experience.

I will be punctual and keep scheduled appointments.

CLIENT

I am aware that the key to my well-being is me.

I am ready to make changes and to sustain change for increasing my health and wellness.

I will commit to assessing my readiness for change and creating an action plan for my goals.

I will explore new ideas, behaviors, and actions that may involve risk-taking and fear of failure and/or fear of

success.

I will take responsibility in learning new lifestyle behaviors.

I will be open and honest so that I can access my deeper wisdom and be more self-aware.

I will integrate self-reflection and self-care practices each day.

I will explore obstacles towards my goals and notice responses to these challenges.

I will be punctual and keep scheduled appointments

Nurse Coach Signature

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Client Signature

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Date

Financial Agreement:

Thank you for choosing our services for your needs. Please read and sign the agreement below. It lays out billing, scheduling and cancellation procedures. If you have any questions, please ask for clarification.

Payment of all fees is expected at the time of service or via credit card on file. We do NOT accept insurance at this time.
I hereby authorize payment of medical benefits directly to Your Nurse Health Coach for all services rendered, where applicable.
Out-of-pocket payments can be made via credit/debit card, and are due on the date of your appointment.
I hereby authorize Your Nurse Health Coach to release to government agencies, insurance carriers and all others who are financially liable for my care, all information to substantiate payments for my care and to permit representatives thereof to examine and make copies of all records related to such care and treatment. I understand that if at any point my insurance coverage changes, I am to notify administrative staff prior to my next visit. Failure to do so will result in being personally and completely responsible for the full amount of all services.
I will be responsible for paying a $50 late cancel fee for any missed or cancelled visits, not made at least 24 hours in advance prior to the scheduled appointment time.
If I default on my account, I understand I will be subject to finance and/or legal fees in addition to the total account balance.

Type Full Name :

agree to the above financial and cancellation policies. In the case of default payment, I am responsible for full payment of the balance, interest accrued, and any collection costs and legal fees incurred to collect on this account. I understand the scope and limitations of my insurance coverage and agree to pay all fees not covered by my insurance plan. I have read, understand, and accept the information and conditions specified in this agreement

Waiver Of Liability:

DISCLAIMERS

I understand that the role of Your Nurse Health Coach is to assist me with Health and Wellness coaching. I am aware that they are not acting in the capacity of a Medical Doctor. I understand that Your Nurse Health Coach does not prescribe medications. I understand that Your Nurse Health Coach, does use holistic and proven therapies to help me resolve my issues.

I understand that if I am under the care of other healthcare professionals and/or currently uses prescription medications, I should discuss any changes with my doctor, and should not discontinue any prescription medications without first consulting my doctor.

I agree that I have chosen to work with Your Nurse Health Coach and understand that the information received is not meant to take the place of other licensed health professionals.

PERSONAL RESPONSIBILITY AND RELEASE OF HEALTH CARE RELATED CLAIMS

I acknowledge that I, the Client, take full responsibility for my life and well-being, as well as the lives and well-being of my family and children (where applicable), and all decisions made during and after the services provided. I assume the risks of the Program/Services.

I release Your Nurse Heatlh Coach, from any and all liabilTextity, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which I, the Client, ever had, now has or will have in the future against the provider, arising from my past or future participation in, or otherwise with respect to, the Program/Services, unless arising from the gross negligence of Your Nurse Heatlh Coach.

CONFIDENTIALITY

Your Nurse Health Coach will keep the Client’s information private, and will not share my, the Client’s, information to any third party unless compelled to by law.

WAIVER OF LIABILITY AND INDEMNIFICATION

I acknowledge that I am voluntarily participating in the services provided by Your Nurse Health Coach and agree to the following:

I waive, release, and discharge Your Nurse Health Coach and their employees from any and all negligence and liability for my death, disability, personal injury, property damages, property theft or claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in their services.
I agree to defend, indemnify, and hold harmless [ORGANIZATION/PROVIDER NAME] and their employees against any and all claims of any nature, including all costs, expenses, and attorneys’ fees, which in any manner result from my participation in their services.

I hereby agree:

Signature

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