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We specialize in Listening, Advising, and Encouraging while providing a confidential, caring, and friendly environment.

Disclaimer:

We are not licensed mental health professionals. We are trained mental health coaches. If you or someone you know is experiencing a physical or mental health emergency, call 911. You may also find more resources here.

Intake Form

Please complete the following information and we will contact you to schedule your first appointment. For immediate assistance give us a call at (850) 422 – 1952.

Step 1 of 4

Your First Name(Required)

Phone(Required)

Date of Birth

Best Time to Contact You(Required)

Mornings (8am - 11am)

Afternoons (12pm - 4pm)

Evenings (5pm - 9pm)

Designated Emergency Contact

Emergency Contact's Name(Required)

First Last

Emergency Contact's Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact's Phone Number(Required)

Consent for Coaching and Limitations of Liability

Limits of Services and Assumption of Risks

Coaching sessions carry both benefits and risks. Coaching sessions can reduce the amount of distress someone is feeling, improve relationships, and resolve other specific issues.

We do not guarantee these improvements and any “cures” for any condition due to the many variables that affect these Coaching sessions. Our prayer is that God will make the improvements needed.

Experiencing uncomfortable feelings, and discussing unpleasant situations and aspects of your life are considered risks of Coaching sessions.

Limits of Confidentiality

What you discuss during your Coaching session is kept confidential. No contents of the session, whether verbal or written may be shared with another party without your consent.

However, we have some exceptions:

We have a duty to Warn and Protect - (C1a) If you disclose a plan or threat to harm yourself, the Coach must attempt to notify your family or designated contact and notify the crisis or legal authorities.
If you disclose a plan or threat to harm another person(s), the Coach is required by law to warn the possible victim and notify the legal authorities.
If you disclose, or it is suspected, that there is abuse or harmful neglect of children or adults (i.e. the elderly, disabled/incompetent), the Coach must report this information to the appropriate state agency and legal authorities.

Coaching with Minors (under the age of 18)

Coaching is effective when a trusting relationship exists between the Coach and minor. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger relationship between children and their parents. However, it is often necessary for children to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom in Coaching sessions.

Except for the situations listed above (C1a.), the Coach will not tell a parent specific the child shares with them in Coaching sessions. This includes behavior that a parent may not approve of but that does not put the minor at risk of serious and immediate harm.

If the Coach believes that it is important for a parent to know what the child has discussed in sessions, the Coach will encourage and help the child find the best way to tell the parent.

Acceptance of Agreement

Are you 18 years of age or older?(Required)

Yes

Client Signature

By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications.

Sign Here:(Required)

Parent or Guardian's Signature

By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications.

Parent or Guardians Sign Here:

“Arise, shine, for your light has come, and the glory of the Lord rises upon you.”

– Isaiah 60:1

Book a Session