RobinA. Williams, Ph.D., CLC

Board Certified Christian Life Coach

Midlothian, Virginia 23113

715-505-2372

Getting Started

This Welcome Packet includes five documents. Please fill in as much information as you feel comfortable with, and only those areas that apply to you. The more information you supply, the better I can serve you. Return all documents signed via e-mail or by mail.

You may fill these forms in on the computer and email them to me at:

1. Client Information

All client information is confidential and treated appropriately. I keep a confidential record of your name, phone number and email address in order to meet the requirements for coach credentialing by the American Association of Christian Counselors.

2. Coaching Relationship

This quick survey gives me an idea of where you are now and where you want to go through our coaching relationship.

3. Getting to Know You

In addition to the information that you provide through these forms, feel free to send me anything else that you think might help me get to know you better: a resume, a Christmas letter, personality or spiritual surveys, compliments of friends, etc.

A picture of you or one of you and your family for my file will help to create a personal connection when we coach and as I pray for you.

4. Life Satisfaction Survey

This survey captures how satisfied you are with different parts of your life at the current time.

5. Coaching and Payment Agreement

Please review these guidelines and procedures before signing and returning this agreement. A clear understanding of these guidelines will keep our professional coaching relationship productive and enjoyable. Keep a copy of this form for your personal records.

RobinA. Williams, Ph.D., CLC

Christian Life Coach

CLIENT INFORMATION

Full Name:

Name you like to be called:

Address:

Email:______Fax:______

Home Phone:______Work Phone:______

Cell Phone:______

Date of Birth:______Marital Status:______

Spouse’s Name:______Anniversary Date:______

Names and ages of children:______

Education:

Employer:______Occupation:______

Briefly describe your occupational responsibilities: Primary duties include providing individual, and couples therapy. Primary responsibilities also include directing the operations and administrative duties associated with outpatient office. This role as owner and administrator involves oversight of all personnel with collateral duties of marketing and program development.

Employment history and work experience: See resume attached.

Robin A. Williams, Ph.D., CLC

Christian Life Coach

COACHING RELATIONSHIP

Have you previously hired a life coach?

How did you hear about me?

What motivated you to hire a life coach?

In what areas can I best coach you? (Examples: encouragement, brainstorming, accountability, clarifying, challenging, new perspectives, processing, discovery, strategy, etc.)

Have you done any work to define your core values? If so, what are they?

Do you have a personal mission or purpose statement? If so, what is it?

What do you want to accomplish through our time together?

On a scale of 1-10, how willing are you to make changes to do things differently in your life?

Not very------1------2------3------4------5------6------7------8------9------10------Extremely 8

Please explain your score:

Describe a great day:

Tell me about your personal interests and hobbies:

List things you like to do:List things you don’t like to do:

List areas in which you are most responsible:List areas in which you are most irresponsible:

What motivates you?

What attitudes, habits, behaviors block your progress?

How do you learn best?

Describe the things that are missing from your life:

Describe the things that would make your life more fulfilling:

List three things you like most about your life right now:

List three things you like least about your life right now:

If you could go back and do three things differently, what would they be?

What drains you and robs you of your joy and motivation?

How do you resolve conflict with those closest to you?

Are you now, or have you ever been in therapy?

For what issues?

What is/was the result?

Describe your spirituality. Explain your relationship with God.

In what ways do you sense God challenging you or nudging you in a different direction or trying to get your attention?

Disciplinary and pruning apply to being redirected back to Him on a number of fronts, namely physical, occupational (calling) and in my marriage.

If you have favorite scripture verses, please list the citations (Chapter:verse(s)

If you had an extra 15 minutes in your day, how would you spend them?

Is there anything else you want me to know about you? If so, explain here:

Life Satisfaction Survey

Often referred to as the Life Wheel, this survey captures how satisfied you are with different parts of your life. Circle or highlight a number (from 1 – 10) next to each life area.

1 = completely dissatisfied (I am not where God wants me to be. This part of my life is entirely unacceptable to me in its current state.)

10 = completely satisfied (I am right where God wants me to be. I couldn’t be happier or more satisfied with this area of life.)

Although your overall satisfaction likely changes from day to day, try to give an overall assessment of where you are at present. Skip any items that don’t apply to you.

Personal Spiritual Life and Growth 7 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Mental / Emotional Health 7 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Physical Health 6 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Marriage / Romantic Relationship 6 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Financial Stability 4 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Home Life (Immediate Family) 6 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Extended Family / In‐Laws 3 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Career / Employment Satisfaction 7 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Recreation / Relaxation 5 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Lifestyle (Degree of Busyness) 5 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Personal Life Fulfillment 7 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Friends / Social Life 4 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Church / Religious Life 4 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10
Physical Comfort (Housing, Car, etc.) 8 / 1‐‐‐‐2‐‐‐‐3‐‐‐‐4‐‐‐‐5‐‐‐‐6‐‐‐‐7‐‐‐‐8‐‐‐‐9‐‐‐‐10

RobinA. Williams, Ph.D., CLC

Christian Life Coach

Midlothian, Virginia 23113

715-505-2372

Coaching and Payment Agreement

Guidelines

  1. I understand that life coaching is a relationship between a coach and an individual. The relationship is designed to facilitate the creation and development of personal, professional or business goals and to develop and carry out a strategic plan to achieve those goals.
  1. I understand that life coaching is a comprehensive process that may involve all areas of my life. It is designed to address issues that I, the client, would like to consider. These areas could include but are not limited to: relationship enhancement, lifestyle management, life balance, health, decision making, career development, spiritual growth and recreation.
  1. I understand that life coaching can involve a number of methods including: brainstorming, values clarification, written assignments, education, goal‐setting, identifying plans of action, accountability, making requests, agreements to change behavior, examining lifestyles and questioning.
  1. I understand that life coaching is an ongoing relationship that may take a number of months to complete.
  1. I understand that either party (client or coach) can choose to discontinue coaching at any time.
  1. I understand that my coach has made no guarantees to me as to the expected outcome of my coaching.
  1. I understand that life coaching is for people who are basically well‐adjusted, emotionally healthy and functioning effectively but who desire to make changes in their lives.
  1. I acknowledge and agree that I am fully responsible for my wellbeing and the choices and decisions I make during my coaching sessions.
  1. I understand that life coaching is not therapy, counseling, advice‐giving, mental health care or treatment for substance abuse. My coach is not functioning as a licensed mental health professional, and coaching is not intended as a replacement for counseling, psychiatric interventions, treatment for mental illness, recovery from past abuse, professional medical advice, financial assistance, legal counsel or other professional services.I understand that professional referrals may be given if it appears they are needed.
  1. I understand that my coach adheres to the American Association of Christian Counselors Code of Ethics.
  1. I acknowledge and agree that if I am currently in therapy or otherwise under the care of a mental health professional, that I have consulted with this person regarding the advisability of working with a life coach and that this person is aware of my decision to proceed with a life coaching relationship.
  1. I understand that life coaching is most effective when all parties are honest and straightforward in their communication.
  2. I understand that my coaching sessions and resulting information are strictly confidential except in those situations where such confidentiality violates the law.
  1. I understand that each person (client and coach) in the coaching relationship is guided by his or her values and beliefs. I know that my coach is a committed follower of Jesus Christ and seeks to live in accordance with this commitment. I know that my coach will be forthright in making this known, but will respect my freedom to make my own choices.

Procedures

  1. I understand that my coaching will be done by phone. These arrangements will be made between the client and coach, and can be changed as needed. If we are doing our session over the phone, I will make the scheduled phone call on time to 715-505-2372. Each session will be 45 minutes in length.
  1. I understand that rescheduling and cancellations need to be made at least 24 hours in advance. Rescheduling for a valid emergency will be allowed otherwise, missed sessions are not made up or refunded.

Payment Options

1. I agree to the Monthly Payment Plan that I have checked below:

( ) Two (2) 45-minute coaching sessions, E-mail* and spot calls** at $225 per month.

( ) Four (4) 45-minute coaching sessions, E-mail* and spot calls** at $450 per month.

( ) Six (6) 45-minute coaching sessions, E-mail* and spot calls** at $650 per month.

( ) One (1) 45-minute coaching session, Email* and spot calls** at $115 per month.

*Emails between calls are included as part of my service, to share praise, ask questions, ask for prayer, etc. I will return your email within 48 hours.

**Spot calls (5-10 minutes) are also included in my services.

2. Personal check made payable and mailed to:

Robin A. Williams

3. Payment must be made before the first day of each month for services to be rendered.

4. If circumstances change and a client interrupts coaching services for a time, pre‐paid funds are credited to the client’s account for future coaching when it works for the client.

Commitment

I have read and agree to the conditions included in the Coaching and Payment Agreement. By entering into this agreement, I agree to hold the coach harmless from all liability.

______

Client Signature Printed Name Date