Let's get started so I can learn more about you!
This application is required to coach with Holly.
Please complete it thoughtfully and honestly.
Holly will follow up with you within 24 hours of completion.
Anything you share in this form is confidential and safe.
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What's your full name? *

 
What name do you like to go by? *

 
How did you find me? *

Ex. Youtube, Instagram, Facebook, an event, Lolë, Soul Space, from a friend, etc.
 
What's the best email address I can reach you at? *

 
What telephone number can I call you at for a quick onboarding chat? *

 
What city are you currently residing in? *

 
How old are you? *

 
When is your birthday? *

 
What medical professionals are you working with right now? *

For example: psychotherapist, nutritionist, homeopathic practitioner, psycho-pharmacologist, or any other medical professional.

Please leave name below, or write "None."
 
Release of Relevant Medical Information *

In the context of my coaching relationship with Holly Mihelic of Holly Michelle LLC, I authorize her to contact other health care professionals that I am currently working with as it pertains to our coaching relationship.

If I am working with a mental health professional (which I have previously disclosed in this application), my practitioner knows that I am working with Holly Mihelic and that our work is not therapeutically based. I understand, and agree, that Holly Mihelic does not represent herself as a mental health professional or as anything else other than a coach.

I am fully disclosing my current mental health care information and am not withholding information that is pertinent to my care.
     
 
Are you willing to share openly and honestly about your life?

For this question and every question you answer moving forward, don't give me the "right" answer. Give me the truth. This is how transformation happens.
 
RATING OF FEARS, BELIEFS & LIFE PRACTICES

Rate the following topics on a scale of 1-8 in terms of how much you’re challenged with each topic. Go with the number that feels right and true, not the one you feel you should be at.
 
Rate your FEAR OF FAILURE. *

 
Rate your BELIEF IN YOUR SUCCESS. *

 
Rate your NEED TO BE PERFECT. *

 
Rate your OVERALL CONFIDENCE IN YOURSELF. *

 
Rate how well YOU COMMIT TO GOALS. *

 
Rate how often you think NEGATIVELY ABOUT YOURSELF. *

 
Rate how often you think NEGATIVELY ABOUT YOUR LIFE. *

 
Rate your ability to SPEAK YOUR MIND. *

 
Rate how well you LIKE YOUR JOB. *

 
Rate your NEED TO PLEASE OTHERS. *

 
Rate your ABILITY TO BE ON TIME. *

 
Rate your WORK | LIFE BALANCE. *

 
Rate your the amount of OVERALL PRESSURE YOU PUT ON YOURSELF. *

 
Rate your TENDENCY TO WORRY. *

 
Rate your relationship with SELF-LOVE. *

 
Rate your level of overall satisfaction in this life category:
FRIENDS & FAMILY. *

 
Rate your level of overall satisfaction in this life category:
FITNESS & HEALTH. *

 
Rate your level of overall satisfaction in this life category:
CAREER. *

 
Rate your level of overall satisfaction in this life category:
MONEY. *

 
Rate your level of overall satisfaction in this life category:
PERSONAL GROWTH & EMPOWERMENT. *

Read a lot of self-help, take strengths tests, invest in personal development events or online programs.
 
Rate your level of overall satisfaction in this life category:
RELATIONSHIP & ROMANCE. *

 
Rate your level of overall satisfaction in this life category:
HOME & ENVIRONMENT. *

 
Rate your level of overall satisfaction in this life category:
FUN & RECREATION. *

Hobbies, pursuit of passions, traveling, etc.
 
Rate your level of overall satisfaction in this life category:
FUN & RECREATION. *

Hobbies, pursuit of passions, traveling, etc.
 
Are there specific life topics you want to focus on in your coaching sessions? *


 
What are you hoping to accomplish within the duration of your coaching package? *

 
If you could wave a magic wand and have the best life ever, what would that look like for you? *

Go into as much detail as you'd like.
 
What would you say is the #1 block or obstacle that's holding you back from living your best life? *

 
Are you currently trying to heal from a traumatic life event? *

Heartbreak, Divorce, Loss of Job, Passing of a Loved One, Life-Altering Diagnosis, etc. 
If no, simply write "No."
 
What are your religious or spiritual beliefs? *

 
A Spiritual Understanding.

Spirit is the energy that animates you and activates your life circumstances. When someone else says, "You have good vibes," they're talking about your spirit. 

Spirituality is the awareness of your energy and the energetic field you choose to co-create your life with.

Do you get what I'm sayin'?
 
Holly incorporates many energetic & spiritual concepts into her coaching practice. Are you open to that? *

(This does not mean you need to alter your religious beliefs in any way. This just means you are open to accepting that there are energetic forces much bigger than yourself & you are willing to begin strengthening your connection to that.)
     
 
ALMOST FINISHED!

Just a few more details...
 
Are you willing to commit to yourself and this coaching experience? *

This means you will show up to your sessions on time and ready to work. You will commit to coaching at least once a week or once every other week throughout your package.

You understand that you will be fully charged for a session if you cancel within the 8-hours leading up to your session. Emergencies are, of course, an exception.
     
 
Are you willing to commit to the homework and Action Steps that Holly gives you after each one of your coaching sessions? *

Holly will hold you accountable and ask for your results, findings and experiences based on the action steps. Completing these are critical to your transformation.
     
 
Your Financial Health. *

Are you in a financially healthy place in order to make an investment in your coaching? 

A payment of $300 for your 4-session coaching package will be required before your first session.
Is this financially feasible for you?
     
 
Confidentiality Agreement *

The conversations that we have within our coaching sessions are confidential and will be protected as such. You agree to not record me in an audio or visual format unless you have received written permission. You also agree not to distribute any original material from me unless you have received written permission. Information will be shared by me outside of our sessions only with your written consent or in the event that a Court Judge demands it, however, the following are instances where I would be obligated by law to break our confidentiality agreement without your permission:

If it is assessed during your participation in coaching sessions that abuse or neglect of children or elders is occurring.

If in my presence you threaten to kill or harm another individual, and I am convinced that you will act on this threat, or that you may lose control of your actions.

If at any time during the course of our sessions, I determine that you are a danger to yourself, I will inform you of that opinion and make every effort to keep you from endangering your life. In some cases this may include notifying the police or family members.

 
The Release of Liability *

The information contained within www.hollymihelic.com or within private coaching sessions or online classes is not a substitute for professional advice such as from a Medical Doctor, Psychiatrist, or therapist of any kind. The information provided by Holly Michelle LLC or Holly Mihelic does not constitute legal or medical professional advice nor is it intended to constitute such advice.

Any decisions you make, and the consequences thereof are your own. Under no circumstances can you hold Holly Michelle LLC or Holly Mihelic liable for any actions that you take. You agree not to hold Holly Michelle LLC, or any employees of Holly Michelle LLC, liable for any loss or cost incurred by you, or any person related or associated with you, as a result of materials or techniques, or coaching, offered by Holly Michelle LLC or Holly Mihelic.

Life Coaching is a service that provides personal coaching to specific individuals and/or groups. The client is aware that coaching is in no way to be construed or substituted as psychological counseling or any other type of therapy or medical advise. The client understands and acknowledges the coach will not be liable legally or otherwise, for the actions the client may or may not undertake as a result of the life coaching sessions. No assumption of responsibility is made, or given, and the client requesting such advice agrees not to hold The Bach Book LLC or Jordan Bach responsible or liable in any form or fashion, for such actions taken of their own accord. The method and process by which this advice and direction are given in no manner whatsoever, written or verbal, constitutes an agreement or liability on the part of the provider and is acknowledged to be different in many ways than clinical and medical counseling.

You agree that using any of these life coaching services are entirely at your own risk. Life coaching services are provided "as is", without warranty of any kind, either expressed or implied, including without limitation any warranty for information services, coaching, uninterrupted access, or products and services provided through or in connection with the service. This service is requested at the client's own choice and with inherent singular responsibility. Any actions or lack of actions, taken by the client of such advice is done so solely by choice and responsibility of the client and is neither the responsibility nor liability of Holly Michelle LLC or Holly Mihelic. The client takes full responsibility in the decisions they make after being coached as well as the consequences. The client enters into coaching with full understanding that they are responsible for creating their own results.

Periodically Holly Michelle LLC or Holly Mihelic may provide links to other web sites or written print material which may be of value, interest and convenience to you. This does not constitute endorsement of material at those sites or any associated organization product of service . It is the responsibility of the user to make their own informed decision about the accuracy of the information at those sites and print material including their privacy policies. In no event shall Holly Michelle LLC or Holly Mihelic be liable for any incident or consequential damages resulting from use of the material.

You shall indemnify Holly Michelle LLC and its associates, in the event of any such claim, including but not limited to any claims made against Holly Michelle LLC or Holly Mihelic, by any person related or associated with you. Nothing in the content materials shall be considered medical, legal, financial, or actuarial advice.

Life Coaching Sessions are for adults 18 or older. Any coaching for a minor will only be done with the express written consent of the minor's parent(s) or legal guardian(s), and only after an initial consultation involving both the minor and the parent(s) or legal guardian(s).

Holly Michelle LLC, Holly Mihelic, and www.hollymihelic.com reserves the right to refuse service for any reason.

Results are not guaranteed. Holly Michelle LLC, Holly Mihelic, and www.hollymihelic.com holds no responsibility for the actions, choices, or decisions taken or made by the client.

Diagnosing psychological or medical conditions is for trained medical professionals (Physicians and Therapists), not for a life coach.

All information shared for billing or for sessions is held in strict confidence. Your personally identifiable information is never sold, traded, or given away.

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