New Client Intake Form

New Client Intake Form – Rob Maroney

Background

I spent 25 years managing Human Resources for large international companies, where I learned a lot about how people work together by observing them in the workplace. I discovered great similarities between relationships at work and how people relate outside of work. This contributed to my passion for helping individuals and couples recognize and change the disruptive patterns that get in the way of healthy relationships.

My background includes a Masters Degree in Psychology, Professional Life Coach Certification, Advanced Diplomas in Biblical Counseling, Christian Life Coaching, and Gottman Therapist Training. I am also associated with Relationship 180, a nonprofit counseling and teaching organization in Orange County, CA.

My approach is to come alongside another person, but with a reliance on God as the true agent of change. The journey of transformation increasingly allows us to relate to others, and ourselves, freely, authentically, and lovingly as God originally designed. This can be a challenging venture, because our patterns of self-protection disrupt this process and often requires the help of another to look not only at the external problems, but also to what’s happening internally at the heart level. My coaching is informed by my experience working with individuals and couples integrating faith-based principles as well as wisdom from psychology.

I am not a licensed psychotherapist or mental health professional; therefore I will give referrals to those areas of expertise if I believe an individual’s problems lay outside the scope of my specialty or abilities.

After over 4 decades of marriage, 3 grown children, 13 grandchildren, and a dozen years in full time Christian ministry we have our own story of repair and recovery. We understand something about the stress, pressures and challenges of sustaining healthy relationships, and welcome the chance to talk with you.

"*" indicates required fields

Are you responding as an individual or a couple?*

*** If replying as a couple, both partners please complete a form ***

Basic Information

Name*

First Last

Date of Birth*

Email*

Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Relationship Information

Marital Status*

Spouse Name*

First Last

How long have you been married?*

How long have you been separated?*

How long have you been divorced?*

How long have you been widowed?*

If prior marriages please describe:

Do you have any children?*

Yes

Names and Ages of Children*

Family History Background

Father's Name*

First Last

Still living?*

Age if Living

Mother's Name*

First Last

Still living?*

Age if Living

Do you have any siblings?*

Names & Ages of Brothers & Sisters*

Please include yourself, and any half brothers and sisters names

Health Information

How Would You Rate Your Health?*

Are you on medications?*

If yes, please list:*

Have you had a history of addiction or has there been addiction in your family?*

If yes, please describe:*

Do you have any history of trauma (physical, sexual, emotional)?*

If yes, please describe:*

Counseling Information

What causes you to reach out to me at this time?*

What have you done about your concern up to this point?*

Is there any other information you think I should know? Please describe.*

Emergency Contact (Name; Phone; Relationship):

Signature: I have read and fully understand this agreement and the stated policies mentioned below.*

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Additional Individual Coaching Information

Appointments and Cancelations

A standard appointment time is 60 minutes in length. Your appointment time is reserved for you. It is your responsibility to notify me at least 24 hours in advance if you are unable to attend. Cancellations with less than 24 hours notice will be charged at 50% of the rate for the session.

Emergency Calls

You may call me at 949-940-5964 at any time and if I am not available you will be forwarded to my private voice mail. I will return your call promptly when I pick up messages. In the event of any life-threatening emergency it is important to seek help immediately by going to the hospital or dialing 911.

Fees

The agreed upon fee for each session will be $75.00 per 60 minute session for individuals and $120.00 for couples. On occasion, at the discretion of the coach, the session may be extended at no additional cost. A receipt may be provided to the client upon request; however, coaching typically does not qualify for insurance reimbursement.

Confidentiality in Couples and Family Coaching

Couples and family coaching may include both joint and individual sessions. In such circumstances the couple or family agrees to waive their right to confidentiality so that information shared in individual sessions may be shared in joint session, at the discretion of the coach, to maintain an atmosphere of openness and honesty.

Agreement

I acknowledge that I have read, fully understand, and agree to these stated policies.

Confidentiality

The material you disclose is confidential and cannot be released without your written consent. There are certain circumstances, however, under which I may be legally required to disclose information. These include:

If there is reasonable belief or suspicion that child abuse has occurred.
If there is reasonable belief or suspicion that elder abuse or dependent adult abuse has occurred.
If you make a threat to harm another person.
If you pose a risk to yourself or others.
If you enter into a legal proceeding in which you raise the issue of your mental status, then the court may order your records.

From time to time, I may want to consult with a licensed therapist regarding your coaching. You will be made aware of these consultations and your confidentiality will be protected. Consultation and supervision are inherent in the standard of care and are supported by the coaching profession.

Work Agreement

It is agreed that the client(s) shall make a good-faith effort at personal growth and engage in the coaching process as an important priority at this time in his or her life (lives).

Termination

Client(s) may terminate this coaching agreement at any time for any reason subject to the payment provisions above. The coach may also terminate the agreement on any grounds through oral or written communication.