GOYOU New Client Intake Conscious Parenting Form

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Date

Section A: General

Name

First

Last

Mobile

Nationality

Country of Residence

Age

Gender

Marital Status

Occupation

Your Interests / Hobbies

Current Medication

Are you currently on any medication(s)? If so, please give details.

Current Mental Health Support

Are you currently under the care of a mental health professional(s)? If so, please give details.

Emergency Contact Name

Emergency Contact Number

Where did you hear about Sandra and GOYOU?

Section B: Current Family

Married / Co-habitating

How healthy is the Parent-to-Parent Relationship?

Engaged and communicating positively
Needs improvements
In distress and conflict

Do you consistently co-parent? What does that look like?

Is either parent absent regularly due to work or other reasons?

Number of children and ages

Anyone else living in the home?

Any pets?

Your Occupation

Your Interests / Hobbies

What are your current life and family stresses?

Section C: Family of Origin – Your Parental Figures (mother, father or whoever held those roles for you: granny, step parent, adoptive parent etc.)

Section C: Family of Origin

Your mother's first name and what did you call her?

List three words to describe your mother

Give one sentence about your relationship with your mother

Your father's first name and what did you call him?

List three words to describe your father

Give one sentence about your relationship with your father

Section D: Your Child(ren)

Your child(ren)'s name and age

List three words to describe each child

Give one sentence about your relationship with each child

Describe your child(ren)'s relationship with other siblings

List grandparents or other important people in your child(ren)'s life and describe their relationship

Does your child access child-care?

What are your child(ren)'s interests / hobbies

Describe your child(ren)'s sleep pattern

Describe your child(ren)'s eating pattern

Describe your child(ren)'s exercise / energy pattern

Have any illnesses or medical concerns been investigated? Please give details

Section E: Parent Style with Challenge

When my child doesn't listen to me, I:

Say the same thing over and over
Get angry and resort to threats, bribes or yelling
Get frustrated and start lecturing or pleading
Stop what I am doing, get down on their level, look into their eyes and speak in a calm and clear voice and let them know I can see they are having a hard time concentrating on my words but that I need them to listen to me for just a few minutes.

When my child has a tantrum at home, I:

Give them what they want so I can get on with my chores
Yell at them to stop
Send then to their room and tell them to not come out until they have calmed down
Take some deep breaths, connect with my child to calm them down and correct them later at a teachable moment.

When my child goes on and on and gets upset after I have said no, I:

Eventually give in because it’s easier
Find myself becoming more and more irritated as their behaviour escalates and eventually I snap and yell or loose it
Tell them to stop being ridiculous and ignore their whinging
Check in on my own energy, breath and stay calm and then empathise with my child and allow them to move through their reaction until they have calmed down

When my child behaves badly in public, I:

Ignore it or give them what they want or tell them Ill get them a treat if they behave so it doesn’t escalate and cause an embarrassing scene in public
Become embarrassed or angry by their behaviour and tell them if they don’t stop immediately that I will take something away (ie treat, TV, toy’s etc)
Ignore them
I don’t worry about what other people think and I take the time needed to connect with my child and try to see what the feelings behind the misbehaviour could be

When my children fight and hit each other I:

I’ve tried everything, so now I just give in and tell them to work it out between the 2 of them and hope no one gets too hurt.
Yell at them both that they should know better and send them to their rooms
If one hits the other I hit them back so they can see how it feels
I don’t take sides even when I have seen who’s hit who first. I listen to both sides, try to hear where the upset has really originated and repeat their sides back to them and ask what they can each do to help the other one

When my child is rude, I:

Sometimes I ignore it, sometimes I get triggered and say “how dare you speak to me like that” and sometimes I try to connect to what’s really wrong
Become mad that they would dare to speak to me like that and either yell or send them to a time out or to their room
Tell them that their behaviour is not acceptable and give them a consequence like no TV or playdates
I don’t take it personally and look at their defensive state as information not resistance, that can help me understand what is really behind why they are being rude

Section F: Reflection for support

Why are you seeking parenting support at this time?

What steps have you taken to date? What worked well? What didn't work so well?

What do you hope to gain from our meetings?

Please describe the current home environment dynamics and mood

Please describe your current parenting style

What areas do you feel are currently healthy in your Parent-Child Relationship?

What areas do you feel are currently causing conflict in your Parent-Child Relationship?

What does healthy communication in your Parent-Child Relationship currently look like? Please give examples.

What does unhealthy communication in your Parent-Child Relationship currently look like? Please give examples.

If you had a magic wand, what would your Parent-Child Relationship look like?

From a realistic perspective, what would you hope your Parent-Child Relationship could look like?

Any additional information that you think is important and would be helpful for me to know?ph Text

Tick to accept the following

I understand I am responsible for my own action and self-care
I understand that coaching / wellbeing results are not guaranteed
I understand that I am responsible for creating my own results
I understand that I am responsible for doing the homework between sessions
I understand that GOYOU is not a clinical mental health service and does not address clinical concerns and disorders
I understand that payment must be paid prior to sessions

Terms and Conditions & Privacy Policy

I understand and agree to the GOYOU Terms and Conditions & Privacy Policy

Terms and Conditions
These terms and conditions should be read in conjunction with the Privacy & GDPR Policies.
Consent
By using this website and service, you hereby consent and agree to the Terms and Conditions.
Security & Confidentiality
GOYOᑌ endeavours to provide a secure and confidential service. The service utilises the Zoom platform with TLS encryption and sessions are conducted in a private and secure environment with no interruptions. The technology equipment is regularly updated with anti-virus software, well maintained, stored in a safe environment and password protected. All sessions are carried out in a secure private environment without interruptions.
Clients are responsible for their privacy and security, and noise cancelling earphones are recommended.
Clients using the services of GOYOᑌ are responsible for the maintenance and protection of their own technology and for regularly updating their security software. Clients are not permitted to record any part of the sessions. Clients are responsible for making the necessary arrangements to ensure confidentiality from their end during sessions and afterwards where devices may be shared. GOYOᑌ accepts no responsibility for client’s devices, nor any technical difficulties occurring in connection with www.getoutofyourownways.com

Personal data is required for GOYOᑌ’s own records and may be stored in a secure file and may not be released to a third party except under court order.
Clients accept that there are limits to confidentiality. While the content of the sessions and the client’s identity is treated with the strictest confidence, this may cease should the client disclose information which indicates that the client’s safety or others is at risk. In all instances where it may be necessary to break confidentiality the client will be informed prior to any action being taken.
All records and data relating to the session remains the property of GOYOᑌ and no part of session content may be used by any other party for publication in any form or use in study without the written consent of GOYOᑌ.
Terms of Use
GOYOᑌ provides professional wellbeing support service focusing on personal development and navigating the regular life challenges that come our way. The four service branches of GOYOᑌ, Life coaching, Conscious Parenting, Mother-Daughter Coaching and Mindful Living, facilitate an accompanied journey into self-exploration. However, clients are fully responsible for their actions, decisions and behaviours, during, between and after sessions.
It is important to understand that GOYOᑌ is NOT a clinical mental health service and does not address clinical concerns and disorders. However, GOYOᑌ can provide suitable referral options for an individual upon request. Should it become apparent during a session that a client may need other services, they will agree to being put in contact with / referred to a suitbale mental health professional.
You must be 18 years of age or older to access GOYOᑌ services, or provide written parental consent.
Clients must complete and sign the new client intake forms prior to their first session of individual or group programs providing relevant information on their current needs and declaring that they understand and agree with the Terms and conditions.
The completed client intake forms will guide whether our GOYOᑌ services are suitable for your current needs. If deemed that our GOYOᑌ services are not a match at that time, a full refund will be provided.
The contract of engagement in sessions with GOYOᑌ is subject to acceptance by the client that the terms of use and the confidentiality and security policy have been accepted and understood. By accepting the terms of use clients permanently agree to release and indemnify GOYOᑌ from all actions, suits, lawsuits and claims originating from sessions provided by GOYOᑌ.
Sessions
Sessions are of a set appointment time. Clients are responsible for ensuring that they are available to start the session on time. As all sessions will end on time, sessions that do not begin on time will be of a reduced time but subject to the full price.
Clients are required to turn on their cameras for every session and ensure their speakers and microphone are working well.
Sessions affected by technical difficulties or cancellations on behalf of GOYOᑌ will be subject to a full refund or a rescheduled session. Clients may end sessions at any time but in the interest of closure all clients will be asked to attend for a closing session.
Cancellations
If an individual appointment is cancelled for a genuine* reason 48 working hours before an appointment there will be no charge. However, if multiple appointments are cancelled, GOYOᑌ retain the right to charge for cancelled appointments.
All appointments cancelled within the last 48 working hours before an appointment, will be charged as it will be deemed too late to offer it to someone else.
Group program appointments will not be refunded for non-attendance.
Cancellations by GOYOᑌ will result in a full refund or a rescheduled session as per the client’s request.
*Medical emergency, bereavement or similar.
Conduct
While sessions provide the space for clients to explore their thoughts and feelings, some of which might be difficult, threatening or abusive behaviour will not be acceptable. Each client is expected to respect any other person attending the session. Disrespectful behaviour may result in the session ending for that client and being liable for the full session cost.
Clients and all users of the site https://getoutofyourownways.com are not permitted to attempt to damage the site in any way through the introduction of viruses, Trojans, trolls, or any form of malicious or harmful technology. Details of any breach of this will be forwarded to the relevant authorities.
Payment
All payments are made through Stripe or PayPal at least 48 hours prior to the appointment time.
In cases where Stripe or PayPal is not an option, alternative payment options can be arranged, at the discretion of GOYOᑌ. For information on cancellations please refer to cancellations section.
Agreement
By accepting the terms and conditions clients agree to comply with the following:
• Clients must be over 18.
• Clients have read and agree to the policy on terms and conditions and understand their implications.
• Clients have completed and submitted the New Client Information Form to GOYOᑌ in its entirety prior to their first session.
• Clients agree that the use of the service is for online wellbeing services and not a clinical mental health service.
• Clients are not permitted to record sessions under any circumstances.
• Clients accept that the publication of details pertaining to sessions must not be undertaken without the prior written consent of GOYOᑌ.
• Clients accept that contact between the client and GOYOᑌ take place within the session, the only exceptions being for the purpose of cancellation or rescheduling or as per contracted by client and GOYOᑌ.
• Clients agree to disclose honestly their medical history and all current medications.
• Clients understand that this is not a free service and that all sessions are subject to payment in advance.
Privacy Policy & GDPR
At GOYOᑌ, accessible from https://getoutofyourownways.com, the privacy of our visitors is a key priority. This Privacy Policy contains types of information that is collected and recorded by GOYOᑌ and how it is used. If you have additional questions or require more information about our Privacy Policy, do not hesitate to contact us.
Consent
By using our website, you hereby consent to our Privacy Policy and agree to its terms.
Log Files
GOYOᑌ follows a standard procedure of using log files. These files log visitors when they visit websites. All hosting companies do this and a part of hosting services’ analytics. The information collected by log files include internet protocol (IP) addresses, browser type, Internet Service Provider (ISP), date and time stamp, referring/exit pages, and possibly the number of clicks. These are not linked to any information that is personally identifiable. The purpose of the information is for analysing trends, administering the site, tracking users’ movement on the website, and gathering demographic information.
Cookies and Web Beacons
This website uses cookies (including third party cookies) to remember choices, improve our services and analyse user behaviour to assist in our marketing and advertising. By clicking “I accept” or by continuing to use our website you give us your permission to use cookies for this purpose.
For more general information on cookies, please read “About Cookies”.
Third Party Privacy Policies
This website may include links to third-party websites, plug-ins and applications. Clicking on those links or enabling those connections may allow third parties to collect or share data about you. We do not control these third-party websites and are not responsible for their privacy statements. When you leave our website, we encourage you to read the privacy notice of every website you visit.
Disclosures of your personal data
We will not share your personal data with a third party without your consent other than as necessary to provide data processing services.
We may have to share your personal data with the parties set out below:
• Service providers who provide IT and system administration services. For example, Paypal or Stripe to process payments for goods and services or Chimpmail (or similar) to facilitate the sending of bulk emails.
• Professional advisers including lawyers, bankers, auditors and insurers who provide consultancy, banking, legal, insurance and accounting services. For example, we require all third parties to whom we transfer your data to respect the security of your personal data and to treat it in accordance with the law. We only allow such third parties to process your personal data for specified purposes and in accordance with our instructions.
General Data Protection Regulation (GDPR)
We are a Data Controller of your information.
GOYOᑌ legal basis for collecting and using the personal information described in this Privacy Policy depends on the Personal Information we collect and the specific context in which we collect the information:
• GOYOᑌ needs to perform a contract with you.
• You have given GOYOᑌ permission to do so.
• Processing your personal information is in GOYOᑌ legitimate interests.
• GOYOᑌ needs to comply with the law.
GOYOᑌ will retain your personal information only for as long as is necessary for the purposes set out in this Privacy Policy. We will retain and use your information to the extent necessary to comply with our legal obligations, resolve disputes, and enforce our policies.
To determine the appropriate retention period for personal data, we consider the amount, nature, and sensitivity of the personal data, the potential risk of harm from unauthorised use or disclosure of your personal data, the purposes for which we process your personal data and whether we can achieve those purposes through other means, and the applicable legal requirements.
If you are a resident of the European Economic Area (EEA), you have certain data protection rights. If you wish to be informed what Personal Information, we hold about you and if you want it to be removed from our systems, please contact us.
In certain circumstances, you have the following data protection rights:
• The right to access, update or to delete the information we have on you.
• The right of rectification.
• The right to object.
• The right of restriction.
• The right to data portability
• The right to withdraw consent

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