Passion to Action Intake Form

Name *

First Name

Last Name

Payment Procedure *

Payment is made through the website before the start of the first session. If paying in full, payments must be made 3 days before the start of the session. If a payment plan is being used, payment is due on the first of each month. $150.00 pays for 3 months of access. If you would like to access the Intensive for additional months after January 15th, the cost is $55.00 for each additional month. Do you agree to these conditions?

Yes

No

Rescheduling *

If you need to reschedule a session or one on one call, please give at least 48 hours’ notice. If you have an emergency, we will work around it and make up the appointment. Do you agree to these conditions?

Yes

No

Services *

If, for some reason, you are not satisfied with offered services, please communicate your findings, and we will work to deliver a service to suit your needs. Do you agree to these conditions?

Yes

No

Confidentiality *

The coach will honor the confidentiality of everything discussed with the client. In addition, the coach will not divulge that the Coach and Client are in a coaching relationship without the permission of the Client. The client may be asked to produce a quote or feedback about the intensive in order to share with potential clients, but not without permission. Do you agree to these conditions?

Yes

No

Agreement *

Agreement: By using this site, you signify your acceptance of these policies. If you do not agree to this policy, please do not purchase our product.

Agree

Disagree