(630) 750-2311

Client Data Form

"*" indicates required fields

Client Data Sheet

MM slash DD slash YYYY
Client Name:
Address
MM slash DD slash YYYY
Spouse/Partners Name:
MM slash DD slash YYYY

No. of Children:

MM slash DD slash YYYY
Please complete as much of the following as possible. If you are unsure of any of these answers, don’t worry as we will work on these things together anyway.
What is your vision? The more succinct you are able to make this, the better. If this is not clear for you, leave this blank for now.
What are you facing right now (if anything) that needs immediate focus or resolution?
What do you consider your strengths?
What is it about you that stops you or makes it difficult for you to meet or exceed goals?
VALUES
Your values are the qualities of life that you find most attractive. They are expressions of your Self and allow you to feel truly fulfilled. What do you feel are your true values? If this is not clear for you, leave this blank for now.
10 GOALS
Name 10 goals (both business and personal) you would like to achieve in the next 90 days
Be as creative as you wish! Detail any important accomplishments, highlights, and aspects of your life that are important for me to know. Please also send a recent picture of yourself that you like!

De-Cluttering

We put up with, accept, take on, and are dragged down by people and situations that we may have come to ig nore in our lives rather than fix. Now is the time to identify those things that drain our energy for positive activi ties. As you think of more items, add the to your list.

You may or may not choose to do anything about the right now, but just becoming aware of and articulating them will bring the to the forefront, where you will naturally start eliminating, fixing, or resolving them.

Energy Drainers At Home
Energy Drainers At Work
 
I strongly believe that we are the creator of our own lives whether we know it or not! Therefore, we might as well know it and create it on purpose. Think about what you want for your life in terms of relationships, finances, living situation, creativity, etc. Think of your life 5 years down the road and what it could be if you start connecting with a higher power and also creating on purpose! What would your ideal life be like? Where would you be living? What is your career like? How do you feel? What are your relhatosihps like? What are your surroundings? What gives your life meaning? What gives your life joy and pleasure? Use the space below to answer all these questions creating your 5 year life vision!

Coaching Agreement

INSTRUCTIONS: Please review and return to me as soon as possible via email with the attachment indicating in the body of the email that you have read and agree with the attached.

(“Client”) and Elizabeth Cermak (“Coach”), and pertains to Life Coaching for Personal or Professional Development which shall occur via telephone, as negotiated between Client and Coach.

Definition of Coaching: “Professional Coaching is an ongoing professional relationship that helps people produce ex traordinary results in their lives, careers, businesses or organizations. Through the process of coaching, clients deepen their learning, improve their performance, and enhance their quality of life. In each meeting, the client chooses the focus of conversation, while the coach listens and contributes observations and questions. This interaction creates clarity and moves the client into action. Coaching accelerates the client's progress by providing greater focus and awareness of choice. Coaching con centrates on where clients are now and what they are willing to do to get where they want to be in the future. ICF member coaches recognize that results are a matter of the client's intentions, choices and actions, supported by the coach's efforts and application of the coaching process.”

- Source: International Coach Federation

The Client understands and agrees to each of the following provisions:

  1. ) I hereby employ Elizabeth Cermak as my "Coach" for the purpose of advising and counseling me with respect to the proper format for Life Coaching for Personal or Professional Development. She may also assist me in structuring, identifying and achieving goals as she has experience in such matters and agrees to render such services.
  2. ) I understand and agree that the Coach is not an "employment agent," "business manager,” or "financial analyst" and that she has not promised, shall not be obligated to, and will not: (1) procure or attempt to procure any employ ment, business or sales for me, (2) perform any business management functions such as accounting services, advice on tax matters or the investment of funds, and (3) will not provide psychoanalysis, group therapy or behavioral ther apy.
  3. ) I further understand and agree that as a specialized form of consulting, Coaching is not the same as professional or licensed therapy; and that I am always free to reject any advice, suggestions or requests made by the coach at any time. My coach is authorized and encouraged to be direct and unconditionally supportive with me.
  4. ) I understand that I (the client) am responsible for the outcome of my coaching and my life decisions. My coach is not held liable for the outcome of the sessions and the decisions I make in my life.
  5. ) I further understand and agree that I am to inform my Coach whenever I am under the care of any healer or li censed physician, therapist or psychiatrist; and/or any time I am taking any prescriptions or drugs.

Scheduled Coaching Sessions:

Client understands and agrees to retain the Coach and meet via Telephone at the rate listed below.

The Client is to make the calls with the coach a priority. The coach will call at the agreed upon time and date. Calls will last approximately 45-50 minutes.

Re-Scheduled & Missed Coaching Sessions: Client understands and agrees to make coaching sessions a priority, and to arrive on time for scheduled appointments. Client further understands and agrees that if they have not rescheduled a call 24 hours in advance, and is not available for the agreed upon appointment, the coach will charge the client a $50 cancel lation/no show fee.

All fees are payable in advance before the session.

AS A CLIENT, I AGREE TO THE FOLLOWING:

  1. I understand and agree that I am fully responsible for my wellbeing during my coaching calls, including my choices and decisions. I am aware that I can choose to discontinue coaching at any time. I recognize that coaching is not psychotherapy and the pro fessional referrals will be given if needed.
  2. I understand that “life coaching” is a relationship I have with my coach that is designed to facilitate the creation/development of personal, professional, and/or business goals and to develop and carry out a strategy/plan for achieving those goals
  3. I understand that life coaching is a comprehensive process that may involve all areas of my life, including work, finances, health, relationships, education, and recreation. I acknowledge that deceasing how to handle these issues and implement my choices is exclusively my responsibility.
  4. I am aware that I can choose to discontinue coaching at any time
  5. I understand that life coaching does not treat mental disorders as defined by the American Psychiatric Association. I understand that life coaching is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care, or substance abuse treat ment, and I will not use it in place of any form of therapy.

Above agreed:

MM slash DD slash YYYY

Client Guidelines

FEE

The fee is $79 for a single 50 minute session. Payments are expected to be made promptly via PayPal. If you buy a coaching package and prefer to not continue, you will be reimbursed for unused sessions at your request. I do not offer reimbursement for used sessions. Remember your results are ultimately up to you.

CALL PROCEDURE

I will call you at the specified time for each session.

CHANGES

I have reserved your time for you. If the need arises, please give me 24 hours notice and we will reschedule. I require a 24 hours notice of changed or canceled appointments. If you do not notify me by email, text, or phone of your cancelled or changed appointment within 24 hours, I will charge a $50 cancellation fee. I request you to make our time together a priority. It is very sacred and special for me, so I encourage you to look at it and respect it the same.

PROBLEMS

If I ever say or do anything that upsets you or doesn't feel right please bring it to my attention. I promise to do what is necessary to have you be satisfied. Honesty and trust are critical for our relationship to grow. I want this to be an open and safe place for you to come with confidence.

CONFIDENTIALITY

Confidentiality is critical to our relationship--our coaching sessions are strictly confidential. Any subject discussed and/or items shared, including such things as personal information, future plans, proprietary information, goals, job and company information, will remain confidential.

TYPE OF RELATIONSHIP

We have entered into a coaching relationship and it is not, nor will there be any type of therapy or psychological coun seling. If these are needed, then it is your responsibility to seek these services from the relevant professional. If there is any question about this relationship, please bring it to my attention immediately.

REFERRALS

My business is grown through referrals. I am very grateful for any referrals you send my way!

FEEDBACK

I improve my offering through client feedback, positive and negative. Included in this Welcome Pack is a form for a testi monial. Within the first month if you feel so compelled I would appreciate a testimonial for use in marketing.

MM slash DD slash YYYY

ICF CODE OF ETHICS

Part One: Definition of Coaching

Section 1: Definitions

• Coaching: Coaching is partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential.

• A professional coaching relationship: A professional coaching relationship exists when coaching includes a business agreement or contract that defines the responsibilities of each party.

• An ICF Professional Coach: An ICF Professional Coach also agrees to practice the ICF Professional Core Competencies and pledges accountability to the ICF Code of Ethics.

In order to clarify roles in the coaching relationship, it is often necessary to distinguish between the client and the sponsor. In most cases, the client and sponsor are the same person and therefore jointly referred to as the client. For purposes of identification, however, the International Coach Federation defines these roles as follows:

• Client: The "client" is the person(s) being coached.

• Sponsor: The "sponsor" is the entity (including its representatives) paying for and/or arranging for coaching services to be provided.

In all cases, coaching engagement contracts or agreements should clearly establish the rights, roles, and responsibilities for both the client and sponsor if they are not the same persons.

Part Two: The ICF Standards of Ethical Conduct

Preamble: ICF Professional Coaches aspire to conduct themselves in a manner that reflects positively upon the coaching profession; are respectful of different approaches to coaching; and recognize that they are also bound by applicable laws and regulations.

Section 1: Professional Conduct At Large

As a coach:

  1. ) I will not knowingly make any public statement that is untrue or misleading about what I offer as a coach, or make false claims in any written documents relating to the coaching profession or my credentials or the ICF.
  2. ) I will accurately identify my coaching qualifications, expertise, experience, certifications and ICF Credentials.
  3. ) I will recognize and honor the efforts and contributions of others and not misrepresent them as my own. I understand that violating this standard may leave me subject to legal remedy by a third party.
  4. ) I will, at all times, strive to recognize personal issues that may impair, conflict, or interfere with my coaching performance or my professional coaching relationships. Whenever the facts and circumstances necessitate, I will promptly seek professional assistance and determine the action to be taken, including whether it is appropriate to suspend or terminate my coaching relationship(s).
  5. ) I will conduct myself in accordance with the ICF Code of Ethics in all coach training, coach mentoring, and coach supervisory activities.
  6. ) I will conduct and report research with competence, honesty, and within recognized scientific standards and applicable subject guidelines. My research will be carried out with the necessary consent and approval of those involved, and with an approach that will protect participants from any potential harm. All research efforts will be performed in a manner that complies with all the applicable laws of the country in which the research is conducted.
  7. ) I will maintain, store, and dispose of any records created during my coaching business in a manner that promotes confidentiality, security, and privacy, and complies with any applicable laws and agreements
  8. ) I will use ICF member contact information (e-mail addresses, telephone numbers, etc.) only in the manner and to the extent authorized by the ICF.

Section 2: Conflicts of Interest

As a coach:

  1. ) I will seek to avoid conflicts of interest and potential conflicts of interest and openly disclose any such conflicts. I will offer to remove myself when such a conflict arises.
  2. ) I will disclose to my client and his or her sponsor all anticipated compensation from third parties that I may pay or receive for referrals of that client.
  3. ) I will only barter for services, goods or other non-monetary remuneration when it will not impair the coaching relationship.
  4. ) I will not knowingly take any personal, professional, or monetary advantage or benefit of the coach-client relationship, except by a form of compensation as agreed in the agreement or contract. ICF – Advancing the Art, Science and Practice of Professional Coaching Page 3 of 4

Section 3: Professional Conduct with Clients

As a coach:

  1. ) I will not knowingly mislead or make false claims about what my client or sponsor will receive from the coaching process or from me as the coach.
  2. ) I will not give my prospective clients or sponsors information or advice I know or believe to be misleading or false.
  3. ) I will have clear agreements or contracts with my clients and sponsor(s). I will honor all agreements or contracts made in the context of professional coaching relationships.
  4. ) I will carefully explain and strive to ensure that, prior to or at the initial meeting, my coaching client and sponsor(s) understand the nature of coaching, the nature and limits of confidentiality, financial arrangements, and any other terms of the coaching agreement or contract.
  5. ) I will be responsible for setting clear, appropriate, and culturally sensitive boundaries that govern any physical contact I may have with my clients or sponsors.
  6. ) I will not become sexually intimate with any of my current clients or sponsors.
  7. ) I will respect the client's right to terminate the coaching relationship at any point during the process, subject to the provisions of the agreement or contract. I will be alert to indications that the client is no longer benefiting from our coaching relationship.
  8. ) I will encourage the client or sponsor to make a change if I believe the client or sponsor would be better served by another coach or by another resource.
  9. ) I will suggest my client seek the services of other professionals when deemed necessary or appropriate.

Section 4: Confidentiality/Privacy

As a coach:

  1. ) I will maintain the strictest levels of confidentiality with all client and sponsor information. I will have a clear agreement or contract before releasing information to another person, unless required by law.
  2. ) I will have a clear agreement upon how coaching information will be exchanged among coach, client, and sponsor.
  3. ) When acting as a trainer of student coaches, I will clarify confidentiality policies with the students.
  4. ) I will have associated coaches and other persons whom I manage in service of my clients and their sponsors in a paid or volunteer capacity make clear agreements or contracts to adhere to the ICF Code of Ethics Part 2, Section 4: Confidentiality/Privacy standards and the entire ICF Code of Ethics to the extent applicable.

Part Three: The ICF Pledge of Ethics

As an ICF Professional Coach, I acknowledge and agree to honor my ethical and legal obligations to my coaching clients and sponsors, colleagues, and to the public at large. I pledge to comply with the ICF Code of Ethics, and to practice these standards with those whom I coach.

If I breach this Pledge of Ethics or any part of the ICF Code of Ethics, I agree that the ICF in its sole discretion may hold me accountable for so doing. I further agree that my accountability to the ICF for any breach may include sanctions, such as loss of my ICF membership and/or my ICF Credentials.

Approved by the Ethics and Standards Committee on October 30, 2008.
Approved by the ICF Board of Directors on December 18, 2008.