Welcome to Empower You Coaching & Programs's Life Coaching

Empower U Coaching & Programs

Full Name:
Email Address:
Phone Number:
Age:
Emergency Contact (Name & Phone):

1. What brings you to coaching at this time?

2. What are your main goals for coaching?

3. What challenges are you currently facing?

4. Have you worked with a coach, therapist, or counselor before?
☐ Yes ☐ No
If yes, please briefly explain:

5. Are you currently under the care of a licensed therapist or medical provider?
☐ Yes ☐ No

What would success look like for you after coaching?

What areas would you like to focus on?
☐ Confidence
☐ Career / Job Search
☐ Emotional Healing
☐ Relationships
☐ Life Transitions
☐ Other: ______________________

By signing below, you acknowledge and agree to the following:

• Coaching is designed to support personal growth and development 
• Coaching is not therapy, counseling, or medical treatment 

• You are responsible for your own decisions, actions, and results 
• Progress depends on your participation and commitment 

• Sessions are kept confidential unless required by law 
• Group sessions (The Healing Circle) rely on mutual respect but cannot guarantee full confidentiality from other participants 

• Payment is required prior to sessions 
• 24-hour notice is required for rescheduling 
• Late cancellations or no-shows may result in forfeited sessions 

• Results are not guaranteed 
• Outcomes vary based on individual effort and circumstances 

• Clients agree to communicate respectfully 
• Disruptive or inappropriate behavior may result in termination of services 

Parent/Guardian Name:
Signature: __________________________

I confirm that I have read, understood, and agree to the terms of this Coaching Agreement. I understand the nature of coaching services and agree to participate fully and responsibly.

Client Name: __________________________
Signature: __________________________
Date: __________________________

Empower U Coaching & Programs
amena@empoweru.life