Draft – divorce coach intake form Divorce Coaching Intake First Name * Last Name * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Cell Phone * Daytime Phone (if different from cell phone) Email * Confirm Email * Preferred Method of Coaching Sessions- * Remote (Video) In Person No Preference What is your relationship/marriage status? * Married Domestic Partnership (other than marriage) Separated Divorced What is your and your spouse/partner's living arrangement? * Living Together Living Apart If the relationship/marriage is ending, who initiated its ending? You Your Spouse It's Mutual Partner First Name * Partner Last Name * Do you have one or more children together? * Yes No Coaching Agreement & Disclaimers Agreement The Divorce Coach is available to you as a thinking partner, sounding board, and support for you to focus on what you want and need from the process of the end of your relationship or the dissolution of marriage (divorce), to help you to move forward through the business of divorce, setting goals and taking actions to move forward, and doing the internal work necessary to go through the process of transition as productively as possible. Disclaimers As the client, you understand that a coach is not a therapist. Coaching is designed to focus on taking the actions to help you accomplish the goals that you define. You accept responsibility for your own mental health throughout the process. The information exchanged between coach and client is confidential except as required by law. As the client, you understand that a coach is not an attorney and cannot advise you on what your rights are or what issues are involved in your case. You accept the responsibility to consult with an attorney regarding any legal matters throughout the process. As the client, you understand that a coach is not a CPA or licensed financial advisor and cannot advise you on financial issues and/or tax matters in your case. You accept responsibility regarding any financial/tax matters throughout the process. Cancellation/Refund Policy Three-Day Cancellation: A client who provides written notice of cancellation within Three (3) business days, excluding weekends and holidays, of executing the coaching agreement is entitled to a refund of all monies paid. Other Cancellations: A client requesting cancellation after the access to or start of the coaching sessions is entitled to a refund of all monies paid, less the non-refundable cancellation fee of $180. Completing the Coaching Agreement: The client may choose to stop coaching at any time, subject to the terms of this agreement. Please put the notification in writing via email. Please include the last date of the coaching session. Coach Contact information Stephen Evans, CDC, CDFA708 Superior St. Suite B Sandpoint, Idaho 83864Phone: 208.263.7100 [email protected] By signing electonically below, I affirm that I have read and agree with the Coaching Agreement & Disclaimers and the Cancellation/Refund Policy. I understand that this form constitutes the agreement with my coach, and I agree that these terms are understood to be fair to both coach and client. * signature keyboard Clear If you are human, leave this field blank. Submit
