Forms and Downloads

Please fill out the following form and e-mail it to drdeanhawaii@mac.com
or Download here.

Personal Information Fact Sheet

All personal information is strictly confidential.
Client Information

Date (mm/dd/yy):
Name:
Address:
Home Phone:
Work Phone:
Mobile Phone:
Which phone number is best?
Fax:
E-mail:

Employment Information

Occupation (what you do for a living):
Employer's Name:

Personal Information

Date of Birth (mm/dd/yy):
Significant other:
Names of Child(ren):
Ages:
How did you learn about us?
Referred by:

Medical Information

Please list any significant medical information and conditions.
Significant medical information and conditions:
Medications including psychotropics:
Herbs / Supplements:
Seeing a Psychotherapist / psychiatrist:
Other pertinent medical information:
How does your schedule look for the next 3 months, vacations, trips etc.?
Anything else you wish me to know?

Fees & Coach Client Agreement

I understand that life coaching is a comprehensive process that may involve all areas of my life, including work, finances, health, relationships, education and recreation. I acknowledge that deciding how to handle these issues and implement my choices is exclusively my responsibility.

I understand that life coaching does not treat mental disorder as defined by the American Psychiatric Association. I understand that life coaching is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment and I will not use it in a place of any form of therapy. I have read the page on the differences between coaching and psychotherapy.

I promise that if I am currently in therapy or otherwise under the care of a mental health professional, that I have consulted with this person regarding the advisability of working with a life coach and that this person is aware of my decision to proceed with the life coaching relationship.

I understand that feeling are normal and healthy part of being a human and that through the coaching relationship, awareness and curiosity will be brought to my feelings so that I can make more informed choices and move into my desired action. I understand that coaching does not deal with the psychological antecedent to emotions-that is the realm of therapy.

Although Doctor Nelson is a Doctor of Chiropractic and a licensed acupuncturist, I understand that coaching and his sessions with me are not for the purpose of treating physical medical problems. Your clinical Doctor of choice should address these concerns.

I have told Dr. Nelson of all medications I am using and am under the care of a medical practitioner for these medications.

Dr. Nelson will recommend a licensed psychologist if emotional or mental illness appears to be an issue.

Fees

My initial fee is __________ for the 12 sessions, which includes a one and a half hour discovery session and 11 half hour sessions (13 hours of coaching time). I like to have payment at first meeting. If coaching together isn’t working, I will return unused portion of money based on a cost per hour (payment divided by hours contracted) minus the prorated time used. I will refund any monies by check. I accept Visa, checks and cash. Hawaii residences get the pleasure of the customary sales tax.

Single, weekly or monthly fees can be discussed.

Please sign that you read and understood this form.

By signing below, I acknowledge that I have read and understand all of the above. (By typing my name, I am agreeing that this is my signature for this agreement.)

Signature / Name:

 

Preparation Questions

Please download these questions or answer them on line. Take time to enjoy and explore these questions, as hopefully they will prime the process of our coaching together. I use the information you provide me with to get a deeper understanding of who you are, what drives you, and what you want to create in life. I would like these questions emailed to me before the discovery session but don’t stress if we need to take time in the session to cover some of them.
What’s going on with you right now?
What does this mean to you?
What do you want for your life?
What issues do you want to work on?
What motivates you in life right now?
What in life is most important to you?
What things give you enjoyment and what makes you enjoy them?
What are your biggest achievements in life so far?
What are the beliefs strengths and state of mind that enabled you to achieve them?
If there were no rules and you couldn’t fail, what would your career/life look like?
What qualities would the person in above question possess?
What patterns of behavior hold you back?
What can I say to you when you are stuck that returns you to action?
Do you have spiritual beliefs and or a tradition to which you belong?
What else do you want me as your coach to know about you?
How do you process things best?
What I expect of my coach is:
When I “slump” how do I want my coach to be with me?
What I never want my coach to do?
What else do you want me as your coach to know about you?

 

Coaching Call Preparation Form

Please download these questions below or answer them online. Print out for your own use to facilitate use of efficient use of time during the coaching session

Call Date: Next Call:

What have I accomplished since our last call?
What did I want to get done but didn’t?
The challenges/problems I am facing now:
The opportunities that are available to me right now:
I want to use my coach during the call to:
What I am committed to do by the next call?