CLIENT CONTACT INFO

Date of Birth

CLIENT WORK INFO

Family Life & Personal history?

Relationship Status

Married

Children?

Children's age(s)

I don't have children of my own, but I do have three step-children. Dealing with the intensity of that can sometimes be a challenge for me.

I am currently working with the following mental- and behavioral-health/wellness providers (e.g., talk therapist, psychotherapist, homeopathic practitioner, psychopharmacologist)

Yes

In the context of my coaching relationship with Gwen Gordon, I authorize her to contact these mental- and behavioral-health providers with whom I am currently in treatment or consultation, insofar as such communication pertains to our coaching work

Yes

Practitioners Contacts

Why Coaching?

What are your goals or desired outcomes from coaching?

I would like to be more future thinking and figure out ways to avoid patterns. I would also like to release pain and things that I have struggled with for a long time. I have a lot of shame that haunts me about things both big and small, so everthing seems to lead back to the feelings of shame. I also am very sensitive and I don't to let people's moods impact me and affect me so much.

Have you tried any methods in the past to achieve these goals?

If so, what did you try?

I have been in therapy for about 7-8 years, and I found that very helpful. I have also done a lot of reading and research on my own. I've done meditation and been very involved in yoga and Buddhist teachings.

Have you worked with a support person before in trying to make these changes?

If so, why do you feel it did not work?

I have not used a support person before other than a therapist.

How committed and motivated are you to stay engaged in the steps needed to reach your desired outcomes?

I am committed.

Personal growth can sometimes bring challenges you may have avoided in the past.

Are you ready to face these challenges?

Yes. I am ready for things to be challenging.

When it comes to making changes, how patient are you with yourself?

I honestly do resist change in general, and I am working on that as well. I think I am open to changing myself and I know that there are changes that need to be made. In my personal life, though, I enjoy a rut. :)

What appeals to you most about the type of life coaching I provide?

I like the idea of trying something new, and I can see that it has worked before.

Group Coaching/Community Enrichment?

Joining Gwen Gordon Life Coaching as group coaching client?

N/A

Would you be interested in group coaching to further your potential and learning about yourself?

Would you be interested in community enrichment meetings to support your personal development?

N/A

I...

I affirm that I am currently feeling medically stable, both physically and emotionally.
I understand that coaching is different from advice-giving or psychotherapy. If I ever feel I need those kinds of professional services, I will reach out for them directly and will not expect them from Gwen Gordon.
I recognize that I am responsible for my own well-being throughout and after coaching sessions, including the choices and decisions I make.
I acknowledge that I’ve had the chance to review this agreement, that I understand what it means, and that I’m choosing to move forward in partnership with these terms.

I certify that I can answer YES to all of the above statements.

I agree...

To the following Guidelines and Conduct for Group Coaching:

Focus on ensuring safety, confidentiality, and mutual respect to foster a supportive environment.
Core rules include:

Maintaining absolute confidentiality of members' information
Attending consistently
Engaging actively without dominating
NO advice giving to a participant
Respecting boundaries by avoiding outside relationships
Abstaining from substances before sessions

I certify that I can answer YES to all of the above statements.

Life Coaching Terms & Conditions

1. Sessions

Each session is a minimum of 60 minutes and is scheduled at least seven (7) days in advance, when possible.
At the beginning of our work—especially when incorporating somatic processing—some clients may benefit from sessions longer than 60 minutes.
If we determine during a session that additional time would be helpful, we may extend when schedules allow at a pro-rated rate of $ per additional 15 minutes or your package rate.
90-minute or 120-minute sessions are also available from the start if you prefer more time to process and integrate.
For phone sessions, I will call you unless we arrange otherwise.
For Zoom or Google Meet sessions, a link will be shared before the appointment.
If you need an urgent same-day session, you are welcome to reach out to see if this is possible.
Group Coaching sessions expire 4 months from date of purchase.

a. Cancellations

A 24-hour notice is required to cancel a scheduled coaching session.
Missed sessions without sufficient notice will be charged in full.
Your credit card on file will be automatically charged or a deduction will be made from your session package for the missed session.

2. Out-of-Session Communications

If you reach out to me (Gwen) outside of a scheduled session time to discuss your session work, you will be charged for that time.
Minimum charge for this service depends on the life coaching package you have purchased.
Emails, texts, or calls discussing session content are billed at the same rate as session fees.
A minimum charge of 15 minutes applies to any out-of-session communication.

3. Coaching Work Between Sessions

In addition to scheduled sessions, you may receive:
- Pre-work assignments
- Homework exercises
- Assigned readings

The more effort you put into these, the more feedback you will receive and the faster you will progress.

4. Collaboration & Coaching Relationship

This is a collaborative journey:
- Ask questions.
- Challenge my point of view.
- Share resources you’ve found.
- Offer insights and feedback.
- Remember: You are the expert on yourself. I am the facilitator supporting your growth.

5. Commitment

A minimum of a 3-month commitment (6–8 bi-weekly sessions) is recommended.
This allows for meaningful progress, as changing habits and thought patterns takes consistent effort over time.
Depending on your goals, longer-term coaching may be necessary to fully achieve results.

6. Payment

Coaching Packages or Individual Sessions are billed prior to the first session.
Payment methods accepted:
- Website payment portal
- Zelle (preferred)
- Apple Pay
- Venmo
- Personal check (made out to Gwen Gordon Life Coach, LLC)

7. Confidentiality

All contacts, information, and records are kept strictly confidential.
Occasionally, information may be shared with other coaches for training or feedback purposes. In these cases:
- The client’s identity will remain anonymous.
- No identifying information will be disclosed.

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I certify I have read the above and agree with the terms and conditons as written