Personal Development Intake Form

Personal Development Coaching Intake Forms

Personal Information Usage Agreement *

I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Personal Information Usage Agreement below

All information collected by Rocky Mountain Brain Integration will be held confidential. Your information will not be shared, sold, or disclosed to anyone outside Rocky Mountain Brain Integration LLC without the client's written consent, or where mandated or permitted by law. Personal Identification Information like names, addresses, email addresses, and phone numbers will be used for identification and contact purposes only. Sensitive Data obtained from questioners, forms, and sessions will be used for services rendered only.

Honesty Agreement *

I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Honesty Agreement below

Honesty is the practice of aligning your words, actions, and representations with what you genuinely believe to be true — refusing to deceive, mislead, or misrepresent reality, even when the truth is inconvenient or costly to yourself. It is not merely the absence of lying. It includes accuracy, transparency, and the courage to speak what is real when silence or distortion would be easier. Honesty is the foundation of all other virtues. It establishes truth as the currency of all interaction. Without it, nothing else can be trusted. I agree to answer all questions honestly and to the best of my ability. Neuro Coding, Brain Integration, Neuro Life Coaching, and other services rendered by Rocky Mountain Brain Integration LLC hinges on your honesty with your coach and yourself. Any form of dishonesty hinders the process and limits results.

My Name *

First

Last

Cell/Text Number *

Email *

On a scale of 1 - 10: How would you rate your life? 0=complete failure; 10=complete success

Selected Value: 0

What is the main challenge in your life you would like to address?

How often does this challenge negatively impact your life? 0=never; 10=daily

Selected Value: 0

I am accepted the way I am *

Please Select the Answer That Best Describes Your Relationship

I am good enough *

Please Select the Answer That Best Describes Your Relationship

I feel free to make choices in my life *

Please Select the Answer That Best Describes Your Relationship

I feel important in life *

Please Select the Answer That Best Describes Your Relationship

I generally trust people around me *

Please Select the Answer That Best Describes Your Relationship

I trust myself *

Please Select the Answer That Best Describes Your Relationship

I trust other people to make correct choices *

Please Select the Answer That Best Describes Your Relationship

I trust myself to make correct choices *

Please Select the Answer That Best Describes Your Relationship

I trust other people to support me *

Please Select the Answer That Best Describes Your Relationship

I trust myself to know what is best for me *

Please Select the Answer That Best Describes Your Relationship

I feel accepted by other people *

Please Select the Answer That Best Describes Your Relationship

I feel safe in my life *

Please Select the Answer That Best Describes Your Relationship

I feel emotional overwhelmed in life *

Please Select the Answer That Best Describes Your Relationship

I feel mentally overwhelmed in life *

Please Select the Answer That Best Describes Your Relationship

I avoid problems in my life *

Please Select the Answer That Best Describes Your Relationship

I avoid conflict in my life *

Please Select the Answer That Best Describes Your Relationship

I am often critical of other people *

Please Select the Answer That Best Describes Your Relationship

Other people are often critical of me *

Please Select the Answer That Best Describes Your Relationship

I feel like I am failing in life *

Please Select the Answer That Best Describes Your Relationship

I feel neglected in life *

Please Select the Answer That Best Describes Your Relationship

I am honest in my daily dealings *

Please Select the Answer That Best Describes Your Relationship

People are usually honest with me *

Please Select the Answer That Best Describes Your Relationship

I easily forgive others *

Please Select the Answer That Best Describes Your Relationship

I usually show compassion toward others *

Please Select the Answer That Best Describes Your Relationship

I am usually respectful to others *

Please Select the Answer That Best Describes Your Relationship

People usually respect me *

Please Select the Answer That Best Describes Your Relationship

I enjoy setting goals and working towards them *

Please Select the Answer That Best Describes Your Relationship

I easily identify my weaknesses and want to improve *

Please Select the Answer That Best Describes Your Relationship

I avoid doing hard things in life *

Please Select the Answer That Best Describes Your Relationship

I affectively regulating my emotions *

Please Select the Answer That Best Describes Your Relationship

I feel competent in life *

Please Select the Answer That Best Describes Your Relationship

I accurately understand other people's point of view *

Please Select the Answer That Best Describes Your Relationship

Other people typically understand my point of view *

Please Select the Answer That Best Describes Your Relationship

I feel confident communicating my needs to other people *

Please Select the Answer That Best Describes Your Relationship

I believe my life is just and fair for the most part *

Please Select the Answer That Best Describes Your Relationship

I feel authentic in my life *

Please Select the Answer That Best Describes Your Relationship

I see my needs are more important than other people's needs *

Please Select the Answer That Best Describes Your Relationship

I enjoy trying new things *

Please Select the Answer That Best Describes Your Relationship

life Other to

Individual Responsibility Agreement *

I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Individual Responsibility Agreement below

By checking this box I understand and agree that Neuro Life Coaching is a self-reflective and personal process designed to support personal growth and transformation. I understand Neuro Life Coaching changes conscious and subconscious Neuro Codes. I agree to complete all assignments in the time allotted. I accept full responsibility for my participation, choices, and results.

Medical Wavier Agreement *

I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Medical Waiver Agreement below

Medical Waiver Agreement:
Client and or Client’s Guardian here in after referred to as “Client” understand and agrees to the following:

1. I acknowledge that Rocky Mountain Brain Integration is not a medical provider and does not offer medical diagnoses, treatments, or prescriptions.

2. I understand that any information provided by Rocky Mountain Brain integration is not a substitute for professional medical advice, diagnosis, or treatment.

3. I affirm that I have consulted with my healthcare provider regarding my medical conditions, and I will continue to do so during my association with Rocky Mountain Brain Integration.

4. I understand that Rocky Mountain Brain Integration may collect and handle my protected health information (PHI) in accordance with Health Insurance Portability and Accountability Act (HIPAA)

5. I authorize the disclosure of my PHI to Rocky Mountain Brain Integration for the purpose of providing non-medical support.

6. I release Rocky Mountain Brain Integration, its employees, and affiliates from any liability for injury, loss, or damage that may result from my participation in Rocky Mountain Brain Integration’s services.

7. I understand the risk associated with any activities or recommendations provided by Rocky Mountain Brain Integration and voluntarily assume these risks.

Copyright and Intellectual Property Protection Agreement *

I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Copyright and Intellectual Property Protection Agreement below

By checking this box I agree the information I obtain from Rocky Mountain Brain Integration is for personal use only and agree to Not reproduce, copy, distribute, teach, sell and/or modify, change, or add to any part of the Neuro Code methodology without express written permission from the creator Trevor J. Dimick. This includes but is not limited to language structure, discovery frameworks, session processes, lists of Neuro Codes, code examples, and the full Neuro Code Editor

Date

Signature *

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