Intake for Cleanse | Virtual Health Coach

Please complete this intake form prior to beginning your cleanse program with Amy.

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Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Goals

What motivated you to sign up for the reset cleanse?

What challenges, if any, do you perceive?

List your health goals

Please list each health goal below as well as anything you have tried to obtain each.

Goal description

What have you tried already?

When you achieve your goal what impact will that have in your life?

Health history

List recent meals

Please share what you have had for breakfast, lunch, and dinner the last two days. Include snacks.

Meal description

Day and time

Do you exercise regularly?

Yes

List exercises

Please list the type, frequency, and duration of any exercises that you do.

Exercise type

Frequency

Duration

List allergies

Please list any allergies and your reaction(s).

Allergen name

Reaction (optional)

List medications and supplements

Please list all medications and supplements that you take. Include over the counter medications as well as prescriptions.

Medication/supplement

Frequency (optional)

List injuries and limitations

List any musculoskeletal injuries or limitations that impact your mobility.

Injury/limitation

Details (optional)

List medical conditions

List any other medical conditions.

Condition

Details (optional)

14 Day Reset Cleanse Client Commitment & Agreement*

Welcome to your Reset!

As your coach, I want to CONGRATULATE you for investing in yourself and in your health in a way you may never have before.
You’ll see from what’s included in this coaching experience that it is designed to deliver an extremely high level of accountability, loving support and the right system, so you make empowered decisions and take bold action toward achieving your goals for your health.
You’ll also see that it includes PRIVATE, one-on-one coaching time with me, so you can accelerate your results and have my health, nutrition and lifestyle savvy focused only on YOU.

Saying “YES” to this experience means showing up for yourself in a whole new way, mentally, energetically, spiritually and physically.
This is the KEY to achieving everything you want. So is asking for support and being open to new ways of thinking. PLUS, being willing to be challenged to go outside your comfort zone will help you reach your health goals much faster.
In order for you to get the most out of the program you agree to make the following commitments.

Your Commitment To The Program Includes:
– Reading, signing and returning this Agreement to me prior to your first session
• Attending all coaching sessions on time and refraining from multi-tasking during the session.
• Being authentic, honest, and speaking up for what you want
• Letting me know about any personal situations that may interfere with your experience in the program
• Letting it be okay not to know all the answers
• Be willing to take risks, try new things and stretch beyond your current experience
• Being responsible for your own results, which includes proactively asking for support, scheduling coaching calls and using your program benefits
• Honoring the investment you are making in yourself by handling any situations that may take you away from your experience
– Being patient with yourself and resting periodically to “catch up”
• Honoring our relationship by being direct, truthful, and open so we can go farther, faster • Celebrating your wins, shifts, achievements and excitement throughout the program
My Commitment To You Includes:
• Believing in you and your ability to achieve your vision of success
• Sharing in-depth information and knowledge with you so you can move forward with your health goals much more quickly than you would on your own
• Allowing you to be 100% authentic and fully YOU
• Holding you accountable to act from your highest self, even when you may not feel that way
• Being in integrity and honest at all times
• Holding high standards for you and for myself (and handling any situation that crosses the line, helping you to resolve and move beyond anything you are putting up with that is not in alignment with your brilliance)
• Being kind and patient with your progress so that you know you always have a safe place to express where you are
• Sharing creative action steps, ideas and inspiration without the need to have you “like” them (if you don’t like an action step or an idea that we create, no problem – we’ll create another one or you’ll be inspired to create your own)
• Laser-coaching you to find solutions to challenges that may come up
• Coaching you to your highest self and to achieve your highest potential
• Knowing that there are unlimited possibilities available to you, no matter what any particular situation looks like
• Caring deeply about you and your success
What You’ll Receive In The Quick Start Program:
• 2 private, One-On-One Coaching Sessions With Me. In these coaching sessions, I’ll share information and customized coaching exercises that are GUARANTEED to accelerate your results and help you achieve major breakthroughs so you can see transformation in your body – and your life – FAST.
• Emergency Text Support Between Sessions, Random text check ins. Emergencies come up, right? That’s why you have access to support between sessions.
• Customized Done-For-You Materials Such As Checklists, Recipes, Handouts And More.
• Personalized App downloaded to your phone with all the materials at your fingertips.
Scheduling:
• Sessions are between 30 minutes, please schedule additional 15 minutes in your calendar in case sessions go over
• To get the most out of your sessions, please arrive to all sessions on time
Cancellation Policy:
• You receive 1 “emergency reschedule” in your Program, which means you can cancel a session within 24 hours and still reschedule the session
• Any other canceled sessions with less than 24 hours notice will be forfeited

INVESTMENT & REFUNDS
Investment for the 14 Day Reset Cleanse is $200.00
• In the event of your absence or withdrawal, for any reason whatsoever, you will remain fully responsible for the entire Program fee and any unpaid balance
• This refund policy exists for your benefit as well, as coaching is a powerful process and at times, you may feel “up against a wall” or as if something isn’t working
• Feeling uncomfortable is often a perfect sign that you are releasing obstacles and limiting beliefs
• My request is that any and all concerns regarding assignments and coaching be addressed directly with me, so I can be the best coach and mentor to you that I can be, and ensure the coaching relationship is in integrity.
• Working together, we will be able to make sure your needs are met.

DISCLAIMER
You understand that the information received from me, Amy Harrington, in connection with the Program or otherwise should not be seen as medical and is certainly not meant to take the place of your seeing licensed health professionals, including your doctor.
You understand and agree that I am not providing medical or nutrition therapy services and will not diagnose, treat or cure in any manner whatsoever, any disease, condition or other physical or mental ailment of the human body. I am not acting in the capacity of a doctor, licensed dietitian-nutritionist, or psychologist, and you have chosen to work with me and participate in the Program voluntarily.
As your Coach, I encourage you to maintain a relationship with your primary care physician or doctor. In the event that you do not have one and/or do not have routine physicals, I encourage you to do so. Do not discontinue or change any treatment plan that you may be on as a result of our sessions without discussing the change with your doctor.

RELEASE
You acknowledge and take full responsibility for your life and well-being, as well as the lives and well-being of your family (where applicable), and all decisions made during and after the Program. In furtherance and not in limitation of the foregoing, you hereby and forever waive, release and discharge me, my heirs, executors, administrators, assigns, officers, agents, employees, representatives, executors and all others acting on their behalf (the “Released Parties”) from any and all claims or liabilities for injuries or damages to your person and/or property or that of your family (where applicable), including those caused by negligent act or omission of any of those mentioned or others acting on their behalf, arising out of or connected with your participation in the Program or in connection with services provided by me or the Released Parties.

LEGAL ITEMS
This Agreement may not be modified without the prior written consent of Client and Coach. The waiver by either party of a breach, right or obligation shall not constitute a waiver of any other or subsequent breach, right or obligation. If any provision of this Agreement is found to be invalid or unenforceable for any reason, the remainder of this Agreement shall remain in full force and effect. This Agreement sets forth the entire agreement between the parties and supersedes all prior proposals, agreements and representations between the parties, whether written or oral, regarding the subject matter herein. Neither party may assign this Agreement without the prior written consent of the other party. This Agreement shall be binding upon and shall benefit the parties and their respective successors and permitted assigns. Except as provided to the contrary herein, those provisions of the Agreement that by their nature and context are intended to survive the termination of this Agreement, shall survive any termination of this Agreement. This Agreement shall be construed and interpreted in accordance with the laws of the state in which the Coach resides without reference to its conflict of law provisions, and with the same force and effect as if fully executed and performed therein. Each Party hereby consents to the exclusive personal jurisdiction of the State and Federal Courts where the Coach resides, and acknowledges that venue is proper only in such courts.

If the terms of this Agreement are acceptable, please consent below. By doing so, you acknowledge that: (1) you have received a copy of this letter agreement; (2) you have had an opportunity to discuss the contents with me and, if you desire, to have it reviewed by your attorney; and (3) you understand, accept and agree to abide by the terms hereof.

IN WITNESS WHEREOF, Client and Coach agree to the terms and conditions set forth in and have duly executed this Client Commitment & Agreement effective as of the date of electronic consent to this agreement.

Coach name: Amy Harrington
CONGRATULATIONS and WELCOME TO RENEWED HEALTH

I consent

Signature*

By signing below, you certify that, to the best of your knowledge and belief, the statements provided here are true and correct. You consent and agree that this agreement and disclaimer may be electronically signed. You agree the electronic signatures appearing here are the same as hand-written signatures for purposes of validity, enforceability, and admissibility.

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