Life/Business Coaching Intake Form

Welcome to your faith-based coaching journey! I’m honored to walk alongside you as you pursue greater clarity, healing, and purpose through Christ. This form outlines important information about our coaching relationship. Please read each section carefully, complete where required, and sign the final agreement.

In His Grace, Earlene Bacon, Faith-Based Life Coach

Select "Next" to continue

First Name *

Last Name *

Preferred Name *

Email *

Phone *

By checking this box, I consent to receive non-marketing text messages from Living in Overflow with Earlene Bacon. Message frequency varies; message & data rates may apply. Text HELP for assistance; reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, and new product updates, among others from Living in Overflow with Earlene Bacon at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance; reply STOP to opt out.

Sex *

Date Of Birth (Select year, then month and date) *

Address

Street Address *

City *

State *

Postal Code *

What Services Would You Like More Information About? (Select All That Apply) Coach *

Living in Overflow Life Coaching

Living in Overflow Business Coaching

Zyto BioScan Holistic Scan & Consultation

Living in Overflow Courses

Young Living Essential Oils & Supplements

Living in Overflow Academy & University (Coming Soon)

Why have you made a decision to hire a Life/Business Coach? *

What do you hope to accomplish if you are accepted as a coaching client? *

Is there anything specific you would like Earlene to know before contacting you? (If nothing, type N/A)

What challenges to you need to overcome? *

What is your current occupation? *

What is your current annual gross income range? *

What are your top 3 goals for coaching? List Goal 1 *

What are your top 3 goals for coaching? List Goal 2 *

What are your top 3 goals for coaching? List Goal 3 *

Briefly describe your relationship with God *

What spiritual practices do you currently engage in (prayer, reading the Bible, worship, etc.)? *

What’s currently holding you back or causing struggle in your life? *

Do you need to consult with your spouse or anyone else who helps you make financial decisions before moving forward? *

Yes — I need to review with my spouse/decision-maker

No — I’m ready to proceed

Scope of Services: I understand that life coaching is a professional relationship focused on personal development, goal achievement, and improvement in various areas of life. Coaching is not therapy, counseling, medical or mental health treatment, or a substitute for licensed healthcare, legal, or financial advice. *

I agree and understand

I do not agree nor understand

No Guarantees: I understand that while coaching is a powerful tool for growth, the coach does not guarantee specific outcomes or results. Success depends on my willingness to engage in the process and take personal responsibility for my actions and choices. *

I agree and understand

I do not agree nor understand

Responsibility and Decision-Making: I acknowledge that I am solely responsible for any decisions, actions, or outcomes resulting from coaching sessions. The coach is not liable for any direct or indirect consequences of my choices. *

I agree and understand

I do not agree nor understand

Health and Medical Disclaimer: If wellness, nutrition, or lifestyle guidance is offered, I understand it is for informational purposes only and not intended as a substitute for professional medical advice, diagnosis, or treatment. I agree to consult my physician or qualified health provider with any medical concerns. *

I agree and understand

I do not agree nor understand

Confidentiality: I understand that all information shared during coaching sessions will be kept confidential unless: 1.) I give written consent to share information. 2.) There is a legal obligation or imminent risk of harm to me or others. 3.) Disclosure is required by law. *

I agree

I do not agree

Please read and sign below. Fees and payment: Zyto Bioscan is $120. Scan session time is 45 minutes max (If additional time is desired for an extended coaching session, you can pay $120 for each additional hour). *A nonrefundable payment in FULL is required to book an appointment. If you are a no-show for your appointment, you will have to pay another FULL payment to reschedule. APPOINTMENT WILL BE CANCELLED IF DEPOSIT IS NOT RECEIVED 3 DAYS PRIOR TO APPOINTMENT DATE. Payment may be sent via Cash App ($Livinginoverflow) or Zelle (404-520-0926). Be sure to confirm Earlene's name, as she will not be responsible for money being sent to the wrong person. You may also use the next page to process your payment via debit or credit card. I have read this Disclosure Statement and Schedule of Fees and have reviewed the services offered, fees, etc. to my satisfaction and understand the foregoing and agree to the terms and conditions set therein. With this understanding, I desire to consult with him/her on my health needs. I agree to be added to Earlene Bacon's email and text list for future correspondence. I also understand that my Zyto report will be sent within 14 business days via e-mail *

Clear