Sign Up for Online Coaching - Dr. Sheron Patterson

Yes!

I want online coaching with Dr. Sheron!

The outline coaching contract must be signed and dated before the start of online coaching.

Online payment must be made before the start of each online coaching session.

One online counseling session is $150.00.

The session is 45 minutes in length via ZOOM.

Five sessions are bundled for cost savings at $500.00.

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Step 1 of 3

Getting to Know You

Coaching is more effective and efficient if you can give me some information about yourself at the beginning. This is confidential information and you are free to not answer any of the questions. I encourage you to be open and share the information in order to get the most from our coaching relationship.

Name*

First Last

Name you like to be called:

Phone (Home):

Phone (Work):

Phone (Mobile):*

Fax:

Email address:*

Occupation:

Employer's name:

Date of Birth:*

Marital status:*

Significant Other's Name:

Name and Ages of Children:

Name

Age

Click the plus sign to add another child.

Life Satisfaction Questionnaire

How satisfied are you with different areas of your life? Circle a number from 1 to 10 next to each of the following areas of life. If you give an item a 1, you are completely dissatisfied with this part of your life. It means, “This part of my life is entirely unacceptable to me in its current state.” A number 10 means, “I couldn’t be happier or more satisfied with this area of life.” Your overall satisfaction will change from day to day, but try to give an overall assessment of where you are at present.

1- Completely dissatisfied 10 – I could not be happier

Physical Health*

Mental/Emotional Health*

Career/Employment Satisfaction*

Financial Stability*

Marriage/Romantic Relationships*

Home Life (Immediate Family)*

Extended Family (Relatives, In-laws)*

Friends/Social Life*

Recreation/Relaxation/Leisure*

Lifestyle (Degree of Busyness and Life Balance)*

Personal Life Fulfillment*

Spiritual Health/Life*

Church/Religious Life*

Physical Comfort (Housing, Neighborhood, Possessions, Cars, etc.)*

Why do you want coaching? Be as specific as possible. Example: “I want to start an exercise program to gain more energy and to lose 30 pounds.” Use extra paper if you wish.*

Are you or have you ever been in counseling or therapy? Yes or No If yes, please explain.*

Describe your spirituality. What is your relationship with God? In what ways do you sense God might be challenging you, nudging you in a different direction, or trying to get your attention.*

What are the most important things (good and bad) happening in your life right now?*

In what ways would you like your life to be different one year from now? Be specific.*

What is getting in the way of these goals?*

List at least three things you procrastinate at -- the things that you’ve been putting off.*

What, if any, are your concerns about coaching?*

Rate the level of stress in your life on a scale of 1 to 10. (1=low and 10=high)*

What are your primary stressors?*

Why did you select me as your coach?*

What would you like me to do if you get behind in progress toward your goals?*

How do you like to be supported or held accountable?*

What else would you like me to know about you?*

Coaching Agreement

Coaching is an ongoing relationship between a coach and a person who desires coaching. We both agree that:

Coaching is not therapy, counseling, advice giving, mental healthcare, or treatment for substance abuse or any addictive behavior. The coach is not functioning as a licensed mental health professional, therapist or counselor, and coaching is not intended as a replacement for counseling, psychiatric interventions, treatment for mental illness, recovery from past abuse, professional medical advice, financial assistance, legal counsel, or other professional services.
Coaching is for people who are basically well adjusted, emotionally healthy, functioning fairly effectively, and wanting to make improvements in their lives.
Coaching is designed to address issues the person being coached would like to consider. These could include (but are not limited to) personal foundation, career development, relationship enhancement, spiritual growth, healthy lifestyle management, life balance, decision-making, and achieving short-term or long-term goals.
Coaching will be an ongoing relationship that may take a number of months, although either party can terminate the relationship at any time. Some or all of the coaching may be through telephone contact.
Coaching can involve brainstorming, values clarification, the completion of written assignments, education, goal-setting, identifying plans of action, accountability, making requests, agreements to change behavior, examining lifestyles, and questioning.
Coaching is most effective when both parties are honest and straightforward in their communication.
If the coaching is to involve payment for services, prior to its beginning both parties will agree to a fee, form of payment, procedures for canceled appointments, and initial length of commitment.
Coaching is a confidential relationship and the coach agrees to keep all information strictly confidential, except in those situations where such confidentiality would violate the law.
Coaching assumes that each person in the relationship is guided by his or her values and beliefs. Your coach is a follower of Jesus Christ and seeks to live in accordance with this commitment. Your coach is honest in making this revelation and respects the different values and beliefs of others. Your coach does not seek to impose his or her values on another, proselytize, condemn, or refuse coaching services to people who do not share similar values and beliefs.
We agree to the following business arrangements: The monthly fee for (number of sessions) (time for each session ex.45 minute) sessions is $150.00. If I do not cancel any session with 24 hours notice I will forfeit the session fee.
I (the person being coached) am committed to creating an alliance with my coach, Dr. Sheron C. Patterson.
Each of the people whose signatures appear below agrees that this agreement represents our mutual understanding of the coaching relationship.
Coaching Fees are Non-Refundable.

DISCLAIMER: The client is the sole decision-maker in the coaching process. Any and all actions or consequences resulting from the coaching sessions are the responsibility of the client. The client releases the coach of all liability pertaining to the services rendered in the coaching relationship.

Signature (client)*

Date*

Signature (coach)

Date

Sessions and Payments

After you submit the coaching agreement, a copy of this agreement and a payment link for your coaching sessions will be sent to you. It is mandatory to complete the payment prior to the beginning of the coaching session. Kindly note that all payments are final and non-refundable.

Payment Link

45-Minute Coaching Sessions*

Total

Please list 5 potential days and times that you are available for online coaching within the next seven days.*

Day

Time

Click the plus sign to add another day and time.