Client Profile

Coaching & Consulting Client Profile

Directions: Please complete this form its entirety.

* Indicates required field

Date: *

Name: *

First

Last

Email: *

Company/Organization (if applicable): *

Website (if applicable): *

Address: *

Telephone: *

City: *

State: *

Zip: *

How were you referred? (Select below) *

Please indicate the type of services you are seeking (select all that apply): *

What are you hoping to gain or accomplish as a result of services? *

Specifically what area(s) would you like to focus our sessions on? *

What barriers are currently preventing you from obtaining the results you desire? *

Please select the Coaching/Consulting Package that best fits your needs: *

Are you currently taking advantage of any specials or promotional packages? (f so, please indicate package or promo code) *

By submitting this Profile, I agree to utilize Gem Makers Coaching Services with the full understanding that Gem Makers, Diamond In The Rough, Nicole Steele, DeYonne Parker, their employees, volunteers and directors are in no way responsible or liable for my decisions, actions and their outcomes. I also agree to hold Gem Makers, Diamond In The Rough, Nicole Steele, DeYonne Parker, their employees, volunteers and directors free of all liability and responsibility for any adverse situations created as a direct or indirect result of a specific referral, advice given, or my actions taken while working with or as a result of receiving coaching services.

In addition to the above, I understand and agree to the following:

I am motivated and committed to taking action on my determined personal and professional goals. I realize that anything less than my intentional full participation will not lead to my success.
I accept full responsibility for myself and any actions I take that might result from Coaching.
I am under the care of a physician and healthy enough to engage in coaching.
I can financially afford the Coaching fee at this time. I agree to pay (or be auto charged) promptly by the first of the month for that month's fee. I agree that ultimately, it is my responsibility that my coach gets paid for the services I use.
I agree to honor my scheduled session times.

I have read this client service agreement and agree to abide by its terms and conditions, and acknowledge receipt of my own copy of this Agreement.

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