A list of priorities and information about me and/or my child:

1. I want to improve the following skills or develop and create the following components to my life/family:
A:
B:
C:

2. I want to resolve the following challenges or problems:
A:
B:
C:

3. I want to eliminate the following tolerations (what I'm putting up with in my life/family):
A:
B:
C:

4. I want to accomplish the following measurable or observable results:
A:
B:
C:

5. At this point, I think that I'd like to make these fundamental changes or shifts:
A:
B:
C:

6. What I/my child want and need most from you, as coach, includes:
A:
B:
C:

7. I want you to know that:
A:
B:
C:

PROFESSIONAL COACHING AGREEMENT

I understand that I am working with Heather Leigh Smith for professional coaching at the agreed fee. I am paying this monthly retainer by check or cash prior to the beginning of the month. We will have scheduled sessions each week by telephone or in person, as deemed most useful. Additionally, we may have other interim though limited exchanges by telephone, voicemail, or e-mail, for no additional charge.

If there are special circumstances or events that require significant time or an additional session, we will renegotiate rates.

All information will be held as confidential unless the client requests otherwise in writing.

Professional Coaching is distinctly different from counseling, psychotherapy, or psychoanalysis, and does not deal with the diagnosis or treatment of emotional problems. Since Professional Coaching does not constitute medical consultation or treatment, any healthcare insurance does not apply.

Signature: Date: