Client Information

Thank you for taking the time to complete these questions. I am excited to begin our work together and the information you provide will help us get started.

Please complete this form prior to your first appointment.

Client's Name

First Name

Last Name

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Birth Date

YYYY

Household Members

Please list name, relation, and age of each person

Current Occupation

Current Employer

Are you being treated for any medical conditions at this time? Yes/No

If yes, how was it helpful to you?

Have you worked with a counselor or coach before? Yes/No

If yes, how was it helpful to you?

Briefly describe why you are seeking parent coaching at this time?

What will be different when the issue(s) is resolved?

What are your greatest assets and how have they helped you navigate difficulties in the past?

What do you appreciate most about the life you are living?

Tell me about the strengths you see in your child(ren) and partner.

What supports do you have in place for you (and your child(ren) and family)?

What are you passionate about and what do you do that "recharges your batteries?”

PAYMENT POLICIES AND PROCEDURES

FEES/PAYMENTS: Payment is due at the time of your appointment via Venmo, Zelle or credit card. Phoenix is unable to bill insurance. Individual (60 mins): $100 Individual (90 mins) $150 Couple/Family (60 mins): $125 Couple/Family (90 mins): $185 COMMUNICATION BETWEEN SESSIONS: Phoenix may email you followup notes between sessions. You may email her between sessions. She checks email and return calls during office hours Monday through Friday, but not during the weekend. She will let you know if she will be unavailable for extended periods of time. CANCELING OR RESCHEDULING: Your sessions is reserved specifically for you. Unless there is a true emergency, you must provide a 24 hour notice to cancel or reschedule. Forgetting or missing an appointment will count as one of your scheduled sessions and you will be charged $50. JOINING YOUR SESSION: If you are meeting Phoenix by phone, call 541-760-0336 at your appointment time. If you are meeting by zoom, Phoenix will send you the link and other details. ***I HAVE READ THESE POLICIES AND AGREE TO THEM:

Client Information

PHOENIX RIES Helping the mind, body & soul to live in alignment through yoga, reiki, & coaching.

PHOENIX RIES
Helping the mind, body & soul to live in alignment through yoga, reiki, & coaching.