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Neurodiverging Coaching Application

Please provide the following information to be matched with a coach. Information you provide is confidential to the full extent of the law. If this form presents challenges for you, please send us an email, voice, or video note to [email protected] for support.
Not ready for coaching yet? Fill out our fit assessment instead to get personalized resource recommendations, or learn more about personalized coaching here.

Basic Information

Name

Year of Birth

Preferred pronouns

Billing Address

Email address:

Phone number:

May we leave a message or text to this phone?

May we leave a message or text to this phone?
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Please share anything you'd like your coach to know about your family situation, such as the names of partners, children, pets, or friends

Emergency Contact Info

Please enter the name and information of an emergency contact. This person will only be contacted by your coach in case of a medical or mental health emergency.

Name

Email

Phone number

Relationship

Where did you hear about us?

Where did you hear about us?

Other:

Coaching Goals

What are the biggest changes you want to make in your life in the next 3 months? 

What are the biggest changes you want to make in your life over the next 3 years? 

What do you most want to achieve for yourself in your life? 

What do you expect to achieve in life as a result of hiring a life coach? 

Have you worked with a coach before or a similar one-on-one relationship (e.g. tennis coach, piano teacher, and therapist)? If so, what worked well for you and what did not work in the relationship(s)? 

How can we best help you in the next thirty days? 

Availability

Approximately when would you like to begin coaching?

How often would you like to meet with your coach? (Every week is most often recommended.)

How often would you like to meet with your coach? (Every week is most often recommended.)
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Please mark your general availability for meetings.

Mornings
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

What time zone are you in?

Is there a specific coach you’re hoping to work with?

You may learn more about all of our highly-trained coaches here: https://neurodiverging.com/about-neurodiverging/
Is there a specific coach you’re hoping to work with?

How Coaching Works

Coaching sessions are held by phone or virtually via Google Meet or Zoom, depending on your preference. Your first meeting with your coach is your introductory session, usually 50-80 minutes. By the end of this session, we’ll have identified 1-3 goals that you’d like to work on together, and have agreed upon some next steps for you to take in the upcoming weeks. 

Coaching is goal-oriented and specific, and the amount of interaction and support you need is unique to your personality and situation. In most cases, coaching is a long-term commitment of 6 weeks to 6 months or more. When you meet with your coach, we can talk together about how we can help you best, and agree on an estimated time-to-goal. 

Session recordings are available upon request. You must let your coach know at the beginning of the session you would like recorded. 

If you have an HSA (Health Savings Account) or FSA (Flexible Spending Account) you may be able to use that for coaching sessions. Please check with your account provider. Coaching is not covered by health insurance in the United States. 

We welcome your requests to work with a specific coach. However, please be aware that any given coach may or may not have openings in their schedule, or may not be the best fit for your specific case. We will assess your case personally and you can be assured that we will assign you the best fit possible. We encourage you to reach out to us via email if you have any questions or concerns. 

Cancellations

If you need to cancel or reschedule a session, we request at least 24 hours notice. Please only cancel when truly necessary. Not having done the homework, or not having made progress on your goals is NOT a good reason to cancel! We’re here to help you with your goals, not judge you. If you haven’t made progress, you need to let your coach know so we can work together to develop a new strategy! 

Equity Pricing
Neurodiverging’s sliding scale ranges between $75-$200 per session, with most folks paying around $110 per session. We have a limited number of lower fee spots available per quarter, which may be requested after submission of this application. Sessions must be paid in full before scheduling with your coach, unless you have previously received approval from us. If you have concerns or questions, please email us: [email protected].
Refund Policy

Rarely, despite best efforts and goodwill on both sides, we may not be the right fit for one another. If for any reason you are unhappy with our services, and you have discussed the issue with your coach first, we will offer a full prorated refund on any unused time you’ve purchased, minus a $30 USD administrative fee. Refunds must be requested via writing within 30 days of your most recent purchase, and may take up to 72 hours to be processed. 

Please sign and date below to affirm your receipt of these policies and procedures. 

Signature

Coaching Limitations

Please read and check each statement and sign below to indicate your agreement with these limitations.

Please read and check each statement and sign below to indicate your agreement with these limitations.

Please sign to accept these terms:

Signature

Coaching Code of Ethics 

Your coach has agreed to abide by the following: 

● I will not knowingly misrepresent my knowledge or expertise either publicly or privately, and I will be transparent regarding my education, certifications, and other qualifications. 

● I will hold all discussions with my clients in the strictest confidence, except where doing so may cause harm to others. 

● I will not provide information or advice that I do not believe in or that I would not personally follow. 

● I will honor all agreements with my clients and others, including contracts, scheduling, and assigned tasks. 

● I will not knowingly take any monetary, professional or other advantage of any coach/client relationship. 

● I will conduct myself in accordance with this code of ethics whenever I am engaged in any coaching relationship or capacity. 

Training

Your coach may engage in training and continuing education pursuing and/or maintaining ICF (International Coaching Federation) Credentials. That process requires the names and contact information of all Clients for possible verification by ICF. Do you agree to have only your name, contact information and start and end dates of coaching shared with ICF staff members and/or other parties involved in this process, for the sole and necessary purpose of verifying the coaching relationship? No personal notes will be shared. 

Your answer to this question will not affect whether you are accepted as a client.
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