Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country What are some roadblocks you have faced in creating a healthy lifestyle? Please check the following challenges that apply to your current lifestyle: Fatigued throughout the day or experience a slump midday Hungry often or not easily satisfied after a meal Loss of appetite in the last few weeks Thirsty often, feel dehydrated often Insomnia or hard time falling asleep Depressed or downcast more than 3x per week Body pain of any kind Brain fog or hard time mentally processing Unusually grumpy or mood swings Digestive issues like bloating, constipation, gas, abdominal pain, or diarrhea I feel pretty good overall, just looking to improve my habits Please explain in more detail here, the challenges you checked above. What is your current weight and height? How would you describe your daily outlook and energy level? ( i.e. downcast, optimistic, stressed, etc.) Are you currently working with a Doctor or Medical Professional? Do you feel heard and understood? Comments, questions, or any other information you'd like to share about your current health status - both physically and mentally: Describe a typical day in regards to how you nourish your body. What time, how much, and what foods do you eat for breakfast, lunch, snacks, dinner, etc? Do you take supplements or vitamins? If yes, list each one and how often you take them. How much water do you drink , typically, in a day? Do you exercise? If yes, what type of exercise and how often? Please share about your biblical health. (Prayer, Bible reading, quiet time, church attendance, etc.) What areas would you like to improve in? How do you believe God views you at this moment? What are your expectations or desires with seeking wellness mentoring? Have you ever had any therapy or counseling before? Yes No What was the result of your counseling? Is there any other information you think I should be aware of before we meet? Thank you SO MUCH for completing my form! Next Step: Expect an email from me to schedule our first coaching session. Name * First Name Last Name This RELEASE of LIABILITY is made and entered into on this date by and between Abiding Leaves Wellness Coaching ("the coach") and name as stated above (client). * MM DD YYYY As a precondition to any and all coaching/counseling/mentoring services to be provided by the coach, the undersigned, in consideration of the services provided by the coach, both parties acknowledging the adequacy of said consideration, does hereby remise and release from any and all injuries, losses, damages, liabilities, defenses, claims, actions, causes of action, suits, debts, promises, demands, or agreements, of whatever nature or kind, known or unknown, whether based in law or in equity, that either party hereto ever had or now has or that any one claiming through or under either party may have or claim to have, which was raised or asserted or could have been raised or asserted against the other party at any time prior to the execution of this agreement, including, but not limited to, any and all claims arising out of, by reason of, or in any way related to the subject matter of the mentoring relationship/services as a direct or indirect result of any involvement Mentee may have with the mentor or the mentor.* I Agree Confidentiality - Personal information or business information supplied by clients in coaching sessions will be treated as confidential. It will not be disclosed to a third party without the client's prior permission, save where required by law or where action might be necessary to prevent harm to the client or someone else. I Agree The terms and conditions below apply to all coaching provided by (“the coach”) to any individual or organization ("the client") and constitute the contract for the service to be provided by the Coach for the client. The term 'coaching' as stated here covers life coaching, personal coaching, health coaching, and family coaching. In return for the fees payable by the client (or by a third party on their behalf), the Coach agrees to provide the service described as Abide in Him Wellness Coaching and in accordance with the terms and conditions set out below. The client agrees to pay fees for the service on the terms and conditions set out below (in situations where a third party pays the fees, the third party counts as an agent acting on behalf of the client.) The date that the first coaching session takes place shall be deemed to be the start date for the service. Where any client is unhappy with any of the terms and conditions they can contact the Coach to discuss any concerns and see if they can be resolved before the first coaching session. Participation by any individual in the first coaching session constitutes acceptance of these terms and conditions. I Agree Responsibilities - The Coach will seek to enable the client to improve their quality of life or level of success and to achieve their desired outcomes. Remarkable results can be achieved where clients follow a clear plan in a committed way. However, the client has sole responsibility for taking important decisions in their life or health. The Coach has no liability for any loss incurred by any client, whether financial or otherwise, following commencement of coaching sessions, or for any perceived failure by the client, whether justified or otherwise, to achieve an improvement in quality of life or health or to achieve their desired outcomes or goals. I Agree Rearranging Sessions If a client needs to rearrange a coaching session, they should provide at least 48-hour notice. No refunds will be given to clients for unused coaching sessions unless 48-hour notice has been given. In exceptional circumstances the Coach may need to rearrange a coaching session. In those instances, she will also give the client 48-hour notice where practical. No more than 2 sessions may be rearranged at no cost, after that, there is a $47 persession charge for the change OR the session is not held (client may choose.) I Agree Disclaimer - The information should not be considered complete and should not be used in place of a visit, call, consultation or advice of your physician or other health care provider. We do not recommend the self-management of health problems. Information obtained by using our services is not exhaustive and does not cover all diseases, ailments, physical conditions or their treatment. Should you have any health care-related questions, please call or see your physician or other health care provider promptly. You should never disregard medical advice or delay in seeking it because of something you have heard or experienced here. This service contains the opinions and ideas of the Coach. It is intended to provide helpful and informative material on the addressed subjects. The Coach is not engaged in rendering medical or any other kind of personal professional services through this program or services. The readers should consult his/her medical professional before adopting any of the suggestions herein. The Coach specifically disclaims all responsibility for any liability, loss, or risk incurred as a consequence of the application of any of the contents of this coaching program. I Agree *Natural Health Client Statement. I hereby attest to the following: That I am here, on this and any subsequent visit which includes Phone, virtual or email appointments, solely on my own behalf and not as an agent for any federal, provincial, municipal or professional agency on a mission of entrapment or investigation. I fully understand that Linda Noder is not a medical doctor and I am not here for medical diagnostic or treatment procedures. The services provided by Linda Noder at Abiding Leaves Wellness Coaching is at all times restricted to education and guidance on the subject of natural health matters intended for general natural health well-being and do not involve the diagnosing, prognosticating, treatment, or prescribing of remedies for the treatment of any disease, or any licensed or controlled act which may constitute the practice of medicine in this state or province. This service is also holistic in nature and not one-on-one nutritional counseling as a State licensed nutritionist would perform. I am a Natural Health Educator and Coach. This agreement is being signed voluntarily and not under any pressure of any kind. I Agree I HAVE READ AND UNDERSTAND ALL OF THE ABOVE: Digital Signature First Name Last Name Date MM DD YYYY Thank you! RELEASE OF LIABILITY FORM / CLIENT TERMS AND AGREEMENT