Client Intake Form (Coaching)

Liight Me Up Again Services

ABN:48532028139

Client Intake Form - Coaching

Before completing this agreement, please read the following Terms and Conditions of Services carefully.

Referrer Details (if applicable):

Informed Consent*

• I am entering a non-clinical support agreement for personal growth and recovery coaching.
• Services are not a replacement for therapy or medical care.
• I understand the limitations of confidentiality:
  • Risk of harm to self/others
  • Legal obligation or court orders
  • Child or vulnerable adult protection concerns

Confidentiality Agreement*

• All shared information is confidential.
• Disclosure occurs only when legally required or in high-risk situations.
• Notes are securely stored.
• Confidentiality continues after service ends.

Service Terms & Conditions*

• Session Duration: Sessions range from 15 minutes to a maximum of 1 hour, depending on the nature of the service and client needs.
• Fees: Fees vary depending on the type and duration of the session. A current fee schedule is available upon request or will be provided at the time of booking. All fees must be paid prior to the session unless alternative arrangements have been agreed upon in writing.
• Client Participation: Active involvement is required.
• Cancellation Policy: 24-hour notice is required. Missed appointments may incur full fees.
• Termination: Either party may end this agreement with 3 days' notice.
• Use of Therapeutic Tools: Breathing exercises, grounding tools, and mindfulness may be used but are not therapy.

International Client Acknowledgment (Only for clients outside Australia)

If you are accessing our services from outside Australia, please read and acknowledge the following:

• I understand that Liight Me Up Again Services operates under the jurisdiction of South Australia, Australia, and that all services provided are non-clinical, non-medical, and not a substitute for therapy or mental health treatment in my country of residence.

Client Declaration & Signature*

• I have read, understood, and agree to all information outlined in this Service Agreement, including the confidentiality policy, informed consent, and terms and conditions, including the refund and cancellation policy.
• I confirm that all personal information I have provided is accurate and up to date.
• I give permission for staff within Liight Me Up Again Services to access and use relevant service information for the purpose of delivering support.
• I understand that this form and all materials provided are for my personal use within session and remain the property of Liight Me Up Again Services. I agree not to reproduce, share, or distribute these materials without written consent. I have read and agree to the Service Agreement.
• I understand that 24 hours’ notice is required for cancellations or rescheduling of sessions. Late cancellations (less than 24 hours) may incur the full session fee. Refunds are discretionary and reviewed on a case-by-case basis. Full details are available in the Terms and Conditions or upon request.
• I consent to being contacted, along with my referrer and/or plan manager (if applicable), for service planning and coordination.