Client Sign-up Form

Thank you for your interest in working with an Integrative Nurse Coach Student.

Name

I understand that my coach is a licensed Registered Nurse and an Integrative Nurse Coach Practicum student who needs to complete free coaching sessions as part of the program requirement.

Email address

Cell Phone

State where I will physically be for coaching sessions

I am a...

Select the coaching session type(s) that you are interested in

When would you like to begin coaching?

ASAP
In the next 2 weeks
In the next 4 weeks

Morning Availability

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Afternoon Availability

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Evening Availability

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My Timezone

US Eastern Time
US Central Time
US Mountain Time
US Pacific Time
Other

Notes

Anything you would like the nurse coach student to know prior to reaching out.

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Source

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I give my permission for a nurse coach student to contact me at the contact information I provided above.

I commit to completing the coaching sessions I have agreed to with an Integrative Nurse Coach Practicum student.

I understand that the Nurse Coach student will ask me to meet via Google Meet and will share a link with me to access this meeting at the times the Nurse Coach student and I agree upon.

I understand the session will be recorded to allow the Integrative Nurse Coach student to transcribe the session for reflection and assignments. The recording will not be shared with others.

I understand coaching is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician with any questions you may have regarding a medical condition or treatment and before undertaking coaching, and never disregard professional medical advice or delay in seeking it because coaching is not a substitute for medical care.

I release the Integrative Nurse Coach Academy, LLC and the International Nurse Coach Association, LLC from all liability related to this activity.

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