Please fill in our online forms below. Coaching Intake Form Coaching Intake Form 1. Contact Data & GeneralName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone* Is it OK to leave a message> Cell PhoneFAX2. Health InformationHealth ConcernsMedications Coaching Disclaimer Form Coaching Disclaimer Form Name* First Last I understand that Carol Michalski, MSW, LCSW will provide me with in person, phone or Skype coaching and/or mentoring sessions. A session may last 1 hour. • Session cancellations and/or rescheduling must be made within a minimum of 24 hours before any scheduled session by phoning 414-331-9905. • It is the role of your coach to act as a guide during the coaching process. The results that you obtain from each session will depend entirely on the responsibility you take for taking action and making the changes you are after. • Coaching sessions are non-judgemental. Coach Disclaimer of Liability: Coaching is not therapy or a medical treatment. I am not diagnosing or treating any medical or psychological condition. I have not promised, shall not be obligated to, and will not act as a therapist providing psychological counseling.Acknowledgement I agree to the above statements Payment is required at the time service is provided. The agreed upon fee per session is: Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY
