Coaching Intake Form – S. R. Booking Portal

Please create an account to continue.

Your account is used to manage appointments (bookings, cancellations, etc) for yourself or your child. The following information will be used to book future appointments. Please remember it! You can request a password reset if you forget.

These intake forms are several pages and cannot be saved mid-way to preserve security. Please allocate 30 minutes to an hour to fill out.

Email(Required)

This email will be used for booking, communication, and reminders.

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Client Name(Required)

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Legal Guardian Name (Under 18 Only)

First Last

If you are registering on behalf of a minor, please write the name of the legal guardian.

Client Date of Birth(Required)

Phone(Required)

Client or Legal Guardian Phone Number

Please select how you were referred to this practice(Required)

Suggestion of a medical professional/therapist

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This helps us understand where our clients are coming from.

Other: Please list

Informed Consent for Coaching

Informed Consent for Coaching Sessions

Disclaimer: Coaching vs. Counselling or Therapy It is essential to understand that coaching is fundamentally different from counseling or psychotherapy. Coaching is a collaborative, goal-oriented process focused on personal and professional development. It centers on helping individuals identify specific goals, develop strategies to achieve those goals, and create action plans to maximize potential. Coaching is designed to enhance performance, focus on future growth, and help individuals overcome obstacles. The process is empowering and forward-thinking, offering tools such as psychoeducation, goal-setting, planning, and skill-building.

On the other hand, counseling and psychotherapy are therapeutic practices aimed at addressing emotional, psychological, or behavioral challenges. These practices involve interventions for mental health conditions, exploring past experiences, and working through emotional difficulties. Therapy focuses on healing and well-being, while coaching focuses on improvement and achievement. Coaching is not intended to diagnose, treat, or resolve mental health concerns. It is a supportive process that provides actionable strategies to achieve success, rather than exploring deep emotional issues. If you are experiencing significant emotional distress, mental health concerns, or require psychological support, it is crucial to seek help from a licensed therapist, psychologist, doctor, or counselor. You are encouraged to access the International Misophonia Foundation’s Clinician Directory here to find appropriate mental health professionals who specialize in misophonia. If you are in need of immediate assistance please go to your local emergency room or dial 911 (or your country’s equivalent). By engaging in coaching with Shaylynn Hayes-Raymond, you acknowledge and accept that coaching services are not a substitute for therapy, psychotherapy, or any form of medical care. You agree to seek appropriate professional assistance if you feel you need it.

Purpose and Nature of Coaching

Coaching is a partnership between you and your coach aimed at helping you achieve your personal and professional goals. It is a creative, thought-provoking process that encourages you to make positive changes and develop the skills and strategies necessary for success. Through coaching, you will receive practical tools and actionable guidance to maximize your potential and performance. Coaching supports you in creating a vision for your future, setting realistic goals, and taking the necessary steps to bring those goals to life.

The coaching process is built on mutual trust and respect, where the coach provides encouragement, support, and insights while you, as the client, actively engage in creating solutions and taking action. The coach will not provide medical or therapeutic treatment. Instead, the coach will guide you in developing personal strategies that align with your aspirations and values.

Confidentiality

Confidentiality is an essential aspect of the coaching relationship. All information shared during coaching sessions will be kept confidential and will not be disclosed to third parties without your written consent, except as required by law. Laws such as PIPEDA (Canada), GDPR (Europe), or similar data protection regulations will be followed.

The coach agrees to keep your information private to the greatest extent possible, but please be aware that there may be circumstances in which confidentiality could be broken, such as if the coach believes you (or a minor or elder) are at risk of harm, if required by a court of law, or if you disclose information about illegal activity.

Distinction from Therapy or Counselling

Coaching is distinct from therapy and counseling. It is not intended to diagnose, treat, or resolve mental health conditions. The focus of coaching is on helping you identify and achieve goals, whether they are personal, professional, or related to managing sensory sensitivities, such as misophonia. The coaching process emphasizes forward momentum and actionable solutions.

In contrast, counseling and psychotherapy are practices aimed at healing emotional pain, exploring unresolved trauma, and addressing psychological difficulties. These therapeutic practices are provided by licensed professionals trained to diagnose and treat mental health conditions.

While coaching can complement therapy, it is not a substitute for professional counseling or psychotherapy. If you are under the care of a licensed therapist or counselor, it is recommended that you inform them of your decision to engage in coaching and discuss how the two processes can work together. By engaging in coaching, you agree to seek the necessary professional help for any mental health concerns you may have and acknowledge that coaching is not intended to replace psychotherapy or counseling.

Acknowledgment and Agreement

By signing this agreement, you acknowledge and agree to the following:

1. Coaching vs. Therapy: You understand that coaching is not a substitute for therapy, psychotherapy, or any form of medical treatment, and is not intended to diagnose or treat mental health issues.

2. Coaching Objectives: Coaching is designed to provide education, tools, and strategies to help you achieve your personal and professional goals. The success of coaching depends on your active participation and commitment.

3. Commitment to Professional Help: If you are experiencing mental health issues, you agree to seek appropriate professional help. This coaching process is not intended to address or resolve mental health concerns and is best used to complement other forms of support when necessary. 4. Personal Responsibility: You understand that coaching results are not guaranteed. Your success depends on your willingness to engage in the process and your commitment to applying the strategies and tools provided.

5. Termination of Coaching: You acknowledge that if at any point the coach determines that the coaching relationship is not benefiting you or if you violate the terms of this agreement, the coach may terminate the coaching relationship.

6. Personal Responsibility for Outcomes: Coaching is a tool to help you maximize your potential, but it is your responsibility to create and implement the changes you desire in your life.

Payment Policy

Payment for prepaid sessions (6 or 10) or group classes are required before coaching begins. Payments for prepaid coaching sessions are to be made within 48 hours of the appointment by credit-card payment. After 48 hours, your card on file will be charged for the service.

Cancellation Policy

You agree to notify Shaylynn Hayes-Raymond of any cancellations at least 48 hours in advance. For one on one (non-prepaid) appointments canceled less than 48 hours before the scheduled time, a cancellation fee equivalent to half the session price will be charged. This policy is in place to ensure that the coach’s time and resources are effectively utilized.

Client Agreement

I, [Client/Guardian], hereby acknowledge and agree to the terms outlined above. I understand the distinction between coaching and therapy, and I agree to seek professional help if needed for any mental health concerns. I accept responsibility for my participation in coaching and understand the potential outcomes depend on my effort and commitment.

Signature of Client (Or Legal Guardian)(Required)

If the client is a minor, the legal guardian is the one to sign this form.

Evironment During Sessions

Creating a conducive environment for Zoom appointments is essential, especially since Shaylynn Hayes-Raymond, has a sensory disorder and requires no visual or auditory distractions. Key considerations include:

Dress properly and maintain a professional demeanor
Ensure the environment is as quiet and non-distracting as possible
Ensure no other people are present in the room.

Please consider the following as Shaylynn Hayes-Raymond has a sensory disorder. By limiting distractions, Shaylynn can pay more attention to you the client. Apologies for any inconveniences with these considerations.

Please do not chew gum, lozenges, or other eating during the appointments (this is due to the sensory disorder), all drinks are fine.
Eliminate auditory distractions like loud yelling or barking dogs, televisions, children playing, or other distracting sounds
Please do not clink nails, play with fidget spinners, or use otherwise distracting tools.
Avoid visual distractions such as ceiling fans, blinking lights, other moving objects in the background (tv, screens, flashing etc)
These measures help create a calm and supportive atmosphere necessary for effective sessions.
In text communication please use 1 period after spaces rather than 2 (this causes visual processing issues), as well as not using text speech such as “u, ur,” in place of “you, your”.

If you have any questions specific to these policies please email contact@shaylynnraymond.com or visit www.sensorydiversity.com for more information on sensory disorders.

Signature of Client (Or Legal Guardian)(Required)

If the client is a minor, the legal guardian is the one to sign this form.

Consent for Supervision

To ensure the best care for you, your counsellor is receiving clinical supervision, as mandated by the College of Licensed Counselling Therapists of New Brunswick. My supervisor is Andrea Sullivan, and you can contact her at hello@andreasullivan.ca or (506) 208-2040.

I meet regularly with my supervisor to discuss my cases. When participating in group supervision, I share non-identifying details of your situation with Andrea or other supervisees in my group. These discussions aim to improve the quality of care I provide, focusing only on the details relevant to specific aspects of your care.

My supervisor uses PowerDiary to securely store supervision records and Heidi Health to generate notes. PowerDiary is compliant with PIPEDA regulations. For more details, please visit PowerDiary Privacy Policy. Heidi Health is also compliant with PIPEDA regulations. For more details, please visit Heidi Health Compliance.

I would like to obtain your consent to discuss our sessions during supervision, ensuring your confidentiality is maintained. Please let me know if you have any questions or concerns about this process.

Please provide your signature to indicate your understanding and consent of the clinical supervision process.

Signature of Client (Or Legal Guardian)(Required)

If the client is a minor, the legal guardian is the one to sign this form.

Payment Information and Cancellation Policy

Even for clients who wish to pay through interac e-transfer, a card on file is required to ensure payment.

Credit Card and Data Security Policy Your security and privacy are our top priorities. To protect your sensitive information, we have established the following guidelines for credit card processing, billing, file storage, and data handling: 1. Credit Card Information Storage and Billing By providing your credit card information, you consent to its secure storage by our third-party payment processors, Stripe or Square. Your card details will not be stored on our website or servers. Instead, Stripe or Square will encrypt and protect your information, which we may use to process payments for outstanding appointments. You will be notified of any such charges, which will be applied in line with agreed-upon appointment and billing policies. 2. File Uploads and Document Security Files uploaded through our platform are never saved directly to our website. Instead, they are securely transferred to an encrypted, off-site storage system. For enhanced privacy, all forms are stored as complete documents rather than plain text, adding an additional layer of security for your personal and sensitive information. 3. Legal Disclaimer By using our services and submitting your information, you acknowledge and agree to the terms stated in this policy. While we work with Stripe and Square to ensure your payment information is processed securely, we do not assume liability for any errors, delays, or issues caused by these third-party processors. In case of unauthorized charges, please notify us, and we will work with Stripe or Square to assist in resolving the issue. This policy is subject to change, and any updates will be posted on our website. By continuing to use our services, you accept the terms of this policy and any future amendments.

Thank you for choosing our services. Before proceeding with your sessions, we want to ensure that you understand and agree to our payment policies. Please read the following carefully and let us know if you have any questions.

Fee for No Shows: A fee of $75 will be charged for appointments missed or cancelled without at least 48 hours notice. This fee is not covered by insurance and is the responsibility of the client. If you have an emergency, please email contact@shaylynnraymond.com and we can discuss whether or not this late fee will apply (only waived in extreme cirumstances)
Credit Card on File: We require a valid credit card to be kept on file. This card will be securely stored and will only be charged in accordance with our policies stated here.
Insurance Coverage: It is the client’s responsibility to understand their insurance coverage, including any deductibles, copays, or limitations on sessions. The client is responsible for all fees not covered by insurance.
Payment Due Date: Payments for the client’s portion of the service fees are due on the same day that the service is rendered. We accept payment by credit card, debit card, or cash.
All payment information is stored with Square or Stripe. We use stringent industry-standard privacy measures.
If you would like to pay by interac e-transfer, please note this in your first appointment. If payment is not made within 48 hours, your card on file will be charged.

By signing below, you acknowledge that you have read and understood the above payment policies and agree to comply with them. You authorize us to keep your credit card information on file and to charge it in accordance with these policies.

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