Coaching Request Form

Today's Date

DateHourMinutesAM/PM Option

His Name

First NameLast Name

Her Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Day Phone Number

Area CodePhone Number

Evening Phone Number

Area CodePhone Number

Email

example@example.com

His Age

Her Age

Number of Children (if any):

List the name and ages of your children (if any):

Is this your first marriage?

How long have you been married/dating?

How did you hear about NAME?

Nature of your marriage coaching need:

Did you or are you at present seeking any other coaching?

YesNo

I voluntarily agree to the Biblical coaching provided by Hobart Assembly of God, Inc. I understand and recognize that such Biblical coaching consists of guidance about ideals, beliefs, and Scripture as interpreted and ministered by the above-named, who has completed the training established by NAME (National Association of Marriage Enhancement) and received the association's designation of certified marriage specialist (CMS).

I recognize and understand I am not receiving secular or psychiatric, psychometric, or psychological coaching.

I understand and recognize that the above-named Biblical coach is not a licensed mental health care provider. The above-named Biblical coach is not holding himself/herself out as a "psychiatrist," "psychometrist," or "psychologist," nor is his/her guidance considered "psychiatry," "psychometric," or "psychology."

I acknowledge and understand that this acknowledgment and consent have the same force and effect regardless of whether the Biblical coaching activities are free instead of a fee being charged for consultation.

I acknowledge and understand that the Biblical coaching received from the above-named Biblical coach does not and will not assess, diagnose, correct, treat, or coach in a professional relationship to assist in, among other things, the following: (a) alleviating mental or emotional illness, symptoms, conditions, or disorders, including alcohol or drug addiction; (b) understanding conscious or subconscious motivations; (c) resolving emotional, attitudinal, or relationship conflicts; or (d) modifying feelings, attitudes, or behaviors that interfere with effective emotional, social or intellectual functioning, and in the event such advice is given concerning these problems of the like, such advice is not given in a professional capacity, but is given by the above named only in his/her recognized capacity as a biblically-based Biblical coach, without any further representation of professionalism.

I acknowledge and understand I must inform the above-named Biblical coach before a Biblical coaching session that I do not desire to participate in Biblical coaching, but rather, I am seeking to establish a professional relationship with a mental health service provider.

I acknowledge and understand that I take full responsibility for my decisions after this coaching session.

I understand that NAME acts as a training association, and designations are for the purpose of identifying completed training without further responsibility.

I have fully informed myself of this Biblical Coaching Acknowledgment and Consent by reading and understanding it before signing it.

His Signature

Her Signature

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NAME - National Association for Marriage Enhancement

NAME - National Association of Marriage Enhancement