Client Intake Form

Thank you for choosing The Mind Studio, and Elynn Teo as your coach. Please take a few minutes to complete this intake form so we can best support your journey.

All information is kept strictly confidential.

First name

Last name

Phone

Birthday

Day

Month

Year

Current Medication (if any)

Emergency Contact & Consent

Please provide an emergency contact and review our policies before completing your intake.

Emergency contact name

Emergency contact relationship

Emergency contact phone number

Confirmation of Coaching Policy

This coaching relationship, as well as all information (documented or verbal) that the Client shares with the Coach as part of this relationship, is bound by the principles of confidentiality set forth in the ICF Code of Ethics. However, please be aware that the Coach-Client relationship is not considered a legally confidential relationship (like the medical and legal professions) and thus communications are not subject to the protection of any legally recognized privilege. The Coach agrees not to disclose any information pertaining to the Client without the Client’s written consent. The Coach will not disclose the Client’s name as a reference without the Client’s consent.

Confidential Information does not include information that: (a) was in the Coach’s possession prior to its being furnished by the Client; (b) is generally known to the public or in the Client’s industry; (c) is obtained by the Coach from a third party, without breach of any obligation to the Client; (d) is independently developed by the Coach without use of or reference to the Client’s confidential information; or (e) the Coach is required by statute, lawfully issued subpoena, or by court order to disclose; (f) is disclosed to the Coach and as a result of such disclosure the Coach reasonably believes there to be an imminent or likely risk of danger or harm to the Client or others; and (g) involves illegal activity.

I understand and agree to the confidentiality policy and consent to The Mind Studio storing my information for the purpose of providing coaching and counselling services.

I agree that it is the Client's responsibility to notify the Coach at least 24 to 48 hours' notice for any cancellation or rescheduling. Changes made inside this window forfeit the session or incur a fee, while emergency exceptions and coach-initiated cancellations ensure fairness for both parties.

Client's signature

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Please sign to confirm your agreement to the above statements.