Intake Forms - Billye Matthews Coaching

Please fill in the following documents. Download, print, and sign. Then text a photo to 520-240-2706. Thank you.

Matthews Coaching

Billye Matthews, BS, MT(ASCP), LM, CPM, Trauma Coach
520-586-3277
[email protected]

Registration

Name (Printed)_________________________________________________________________________________________________Date____________________________

Address________________________________________________________________Phone____________________________________________ Age__________________

Email________________________________________________________________ Spiritual preference if you have one _____________________________________

Is there anything else you’d like me to know? __________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________

Informed Consent

I am not a psychologist, psychiatrist, or mental health therapist, or counselor. I am a trauma coach using mainly body based techniques, and exercises. My goal is to help clients gain knowledge of their own traumas and release these traumas from their bodies. The tools used are client-led and designed to increase resiliency and better self-regulation. I am a teacher, sharing what I have learned.

I cannot take away your trauma. However, I can help you learn to deal with it in a more healthy way. I want you to feel safe. If at any time you don’t please tell me. Please ask me any questions you might have and I will answer them to the best of my abilities. I will provide other resources for you if you need more advanced work.

You have the right to refuse or terminate our relationship at any time. I do not diagnose anyone or anything. I will not disclose your information without your written consent, unless it is apparent that you are a threat to yourself or others, or information indicates neglect or abuse of a child or dependent adult.

The program is 6 weekly classes. The initial class is an hour and a half which is $90. The remainder of the classes are one hour long at $60 per class. Additional class time is available if needed. A sliding scale is also available.

I,_______________________________________________________________________, have read the above information and agree that I would like to work with Billye Matthews with the conditions stated above.

Client Signature __________________________________________________________________________________ Date__________________________________

Coach Signature__________________________________________________________________________________ Date__________________________________