Parent Coaching Enrollment Form - Connexted Coaching

Patient Intake Form (#11)

Personal Information

First Name

Last Name

Client Date of Birth

Prefered Name / Nickname

Client Gender

Phone no.

Emergency Contact

Spouse Name

With whom do you live?

Marital Status

Married

Unmarried

other

Marital status(other)

Occupation

May I leave a text or voice message? (Yes/No)

Yes

Preferred method for homework/resources (Email / WhatsApp)

2. Motivation for Seeking Parenting Coaching

Where did you hear about Evergreen Coaching?

What led you to seek coaching support?

Have you received therapy, counselling, or coaching before? (If yes—brief description)

What outcomes would you like us to achieve together?

How will you know our coaching process has been successful?

Section 3: Your Familiarity With Temperament & Evergreen Parenting

This helps me understand how much background you already have. No right or wrong answers — just to help me.

Have you been exposed to temperament or Evergreen Parenting before? (Select all that apply)

How familiar do you feel with temperament in general? (1 = Not at all, 4 = Very familiar)

1) I’m not familiar at all

2) I know a little

3) I understand quite a bit

4) I’m very familiar and comfortable with it

If you know it, you may write your or your child’s temperament type below:

4. Your Child/Children – Brief Snapshot

For each child: Name, Gender & Age, Temperament (if known), Current concerns

6. Emotional, Mental, or Medical Information

(Optional – only share what you feel safe sharing)

Is there anything in your emotional or mental health history that could impact our coaching?

Any major stressors in the last 12 months?

Any medical conditions I should be aware of as your coach?

Current medication (optional)

7. Spiritual Perspective (Optional)

Describe your spiritual view if you’d like it included in coaching.

Do you want faith-based aspects included?

Coaching Agreement (Ethics & Expectations)

As your coach, I commit to:

Keeping everything confidential unless:
- You pose a danger to yourself or someone else
- A minor or elderly person is being harmed
- I am required by law to disclose information
Operating within my scope as a certified Evergreen Parenting Coach and not as a therapist.
Referring you to a professional if your needs fall outside coaching.
Providing a safe, respectful, faith-aligned coaching environment.
Helping you explore goals, patterns, temperament insights, communication, boundaries, and family dynamics.

Your role as the client:

You voluntarily participate in coaching.
You understand coaching is not therapy, medical treatment, or crisis intervention.
You take responsibility for decisions and actions in your home and family.
You agree to be honest, open, and willing to explore new strategies.
You will disclose any important mental-health background relevant to the coaching process.
You commit to communication that is respectful and direct.

Sessions, Payments & Cancellations:

Sessions are 60 minutes unless otherwise agreed.
Payment is due before each session (unless otherwise agreed) via EFT, PayFast, or another agreed method.
Cancellations made at least 24 hours in advance may be rescheduled within 60 days.
Repeated last-minute cancellations may result in ending the coaching agreement.
Your coach will contact you on the agreed platform (Zoom, WhatsApp call, or in-person) at the session time.
Please do not record any part of a session without explicit permission.

I have read, understood, and agree to the Evergreen Parenting Coaching Agreement.