mANDATORY Client Participation Form Name * First Name Last Name Email * Date of Birth * Relationship Status * De-facto Married Contemplating Separation De-facto Contemplating Separation Married Separated De-facto Separated Married Divorced Partnered Other Contemplating Separation Other Separated Other Single never married or de-facto Children * No children Children of the relevant relationship Children of past relationship/s What motivated you to engage in this coaching, course or program? * What do you hope to achieve out this coaching, course or program? * How would you describe the existing dynamics between yourself and your current or former spouse/partner? What challenges are of most concern that you hope will improve? * Do you understand and agree that no legal, financial or professional advice will be provided during this coaching, course or program * Yes No Do you understand and agree that your results from participating in this coaching, course or program depend upon your capacity to consider new perspectives and the extend of your engagement in recommended tools and practices * Yes No Do understand that group programs are designed to be a safe space for group sharing and do you agree to maintain the privacy and confidentiality of other participants within any group offering you are registered to participate? * Yes No Not registered for a group program Do you understand and agree that all group offerings will be recorded and copies provided to all participants and that further, such recordings may be utilised by Kara as she may see fit in the course of her business? * Please note that you will be provided the opportunity to remain anonymous by choosing an alternative screen name, turning off your camera and participating in the chat box in lieu of voice participation. If you elect to identify yourself with name, video and void participation, you do so with full consent of your identity being revealed within the recording. Yes No Not registered for group offerings Thank you!
