Therapy/Coaching Form - Rosjke Mother-Daughter Coaching International

Confidential

Date*

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell*

I can leave a message*

Yes
No

Email*

Age*

Please enter a number from 1 to 100.

Occupation*

Please X if you want*

Individual Therapy/Coaching
Mother-Daughter Couples Therapy/Coaching

If you want mother-daughter couples therapy/coaching (for daughters 18 years and older), both need to complete this Intake Form.

What is your mother’s or daughter’s name?

First Last

Please X if it’s okay that I*

Yes email you
No email you

Doctor´s Details

Name*

First Last

Phone*

How did you hear about me?*

Friend
Doctor
Internet

Office Policy

1. Payment is due before the session. Invoices are emailed through Square. Services are fee-for-service only. It is up to the client to seek insurance reimbursement.
2. If you need to cancel or reschedule your appointment, please give a full 48 hours’ notice, otherwise you will be charged in full for the session, regardless of reason. The only exception is for power and internet outage.
3. I will be waiting for you on Zoom a few minutes before your appointment time. Because there are clients booked in after you, I will not be able to make up the time if you are late for your appointment. If you are late, or do not show up, you will be charged in full for your appointment. It is your responsibility to check that you have the correct time zone difference.
4. It is your responsibility to make sure that your Zoom audio and camera are working, and to find a quiet, private space to have your session. If Zoom fails, we can continue the session on your cell (U.S only) or we can reschedule. You will not be charged if Zoom fails.

My signature below declares that I understand and agree with the terms and conditions of the coaching/therapy relationship. I understand that I am responsible for my own actions and self-care, and coaching/therapy results are not guaranteed. I am entering into coaching/therapy with the full understanding that I am responsible for creating my own results.

Signature*

Mother-Daughter Therapy/Coaching
Client Information

Confidential

Doctor´s Details

Office Policy

First Questionnaire

Second Questionnaire

Mother-Daughter Therapy/Coaching Client Information

Confidential

Doctor´s Details

Office Policy

First Questionnaire

Second Questionnaire

Mother-Daughter Therapy/Coaching
Client Information