top of page
shutterstock_1314102992.jpg

FORMS

Before we begin working together, please take a few moments to read and complete the forms below: Intake Form, Informed Consent, and Cancellation Policy. Your signature is needed on each. 
shutterstock_1314102992.jpg

Coaching Intake Form

Personal Information

Current Health & Wellness Status

How would you rate your current overall health?
Excellent
Good
Fair
Poor
Are you currently under the care of a physician or other healthcare provider?
Yes
No

Wellness Goals & Motivation

What specific areas would you like to focus on? (Check all that apply)

Mental & Emotional Wellness

Are you currently working with a mental health professional?
Yes
No
How would you rate your current emotional wellbeing?
Excellent
Good
Fair
Poor

Additional Information

shutterstock_1314102992.jpg

Informed Consent

Informed Consent, Hold Harmless Agreement, Liability Waiver

I understand and acknowledge:

Nature of Services:

  • Wellness coaching and hypnotherapy services provided by Tight Line Wellness and Training, LLC are not a substitute for medical care, mental health treatment, psychotherapy, or nutritional counseling by licensed medical or mental health professionals

  • The coach is not acting as a licensed healthcare provider, therapist, or medical professional

  • Wellness coaching focuses on goal-setting, accountability, and behavior change strategies

  • Hypnotherapy services are complementary wellness practices and not medical treatments

Medical Consultation:

  • I should consult with my physician or appropriate healthcare provider before making significant changes to my diet, exercise routine, lifestyle, or before beginning hypnotherapy if I have any medical or mental health concerns

  • I will inform my coach of any medical conditions, medications, or health concerns that may affect my participation

  • I will continue to work with qualified healthcare providers for any medical or mental health issues

Personal Responsibility:

  • I am responsible for my own choices, actions, and results

  • I understand that coaching and hypnotherapy outcomes depend on my commitment, effort, and follow-through

  • No specific results or outcomes are guaranteed

  • I can discontinue coaching services at any time

Confidentiality:

  • All information shared will be kept confidential except where required by law (such as risk of harm to self or others, or suspected abuse)

Hold Harmless & Liability Release:

  • I agree to hold harmless and release from liability Tight Line Wellness and Training, LLC, its owners, employees, agents, and representatives from any and all claims, damages, losses, or expenses arising from or related to my participation in wellness coaching and/ or hypnotherapy services

  • I acknowledge that participation in wellness coaching and hypnotherapy is voluntary and at my own risk

  • I understand that wellness coaching and hypnotherapy involve discussion of personal matters and lifestyle changes that I choose to undertake of my own free will

  • I release Tight Line Wellness and Training, LLC from any liability for injuries, damages, or losses that may occur as a result of my participation in these services, except in cases of gross negligence or willful misconduct

I have read, understood, and agree to all of the above statements.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Cancellation Policy Agreement

I understand the cancellation policy: Clients must provide at least 24 hours advance notice to cancel or reschedule appointments. Cancellations with less than 24 hours notice will be charged at the full session rate. Emergency situations will be handled on a case-by-case basis.

Tight Line Wellness and Training LLC

Laura Holtz

Lauraholtz@me.com

shutterstock_1314102992.jpg

Wellness Coaching Agreement

Wellness Coaching Agreement

Client:

  1. I am ready and able to invest the time necessary to make improvements to my overall  well-being.  

  2. I acknowledge that I am fully responsible for my own progress through my choices and  decisions during this process.  

  3. I will participate wholeheartedly with my coach and will commit to being on time to our  sessions. 

  4. I agree to openly and honestly share any personal information related to my wellness and  progress. 

  5. I understand that information discussed will be held as confidential unless I state  otherwise, in writing, except as required by law. 

  6. I understand I may have set backs in my behaviors and that these are a normal part of  behavior change that may be used positively to establish new behaviors. 

  7. I understand that I need to ask for the resources, support and feedback I need from my  coach. 

  8. I am aware that I can choose to discontinue coaching at any time during this process if I  feel this service is not meeting my needs. 

  9. I recognize that coaching is not a substitute for counseling. 

Coach:

  1. I will facilitate an agreement that makes clear the nature of the wellness coaching  process. 

  2. I will support you as you create your own wellness plan and path to change.

  3. I will encourage you as you build the ability and confidence to reach your goals and a  higher level of well-being. 

  4. I will listen to you attentively and without judgment or my own agenda.

  5. I am committed to being honest and forthright with my feedback. 

  6. I will promote realistic expectations throughout our discussions and with goal setting.

  7. I will ask questions when needed and encourage you to arrive at your own answers.

  8. I will assist you in identifying creative solutions as you work through barriers that may  arise. 

  9. I will ask your permission before providing advice or direction. 

  10. I will make the appropriate referrals for topics that may arise outside of my scope of  practice.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Laura Holtz

Tightline Wellness and Training LLC

bottom of page