Personal Development Intake Form

Personal Development Coaching Intake Forms

Personal Information Usage Agreement *

I Agree to the Following Personal Information Usage Agreement

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 Agree to the Following Honesty Agreement

I agree to answer all questions honestly and to the best of my ability. Brain Coding, Brain Integration, Life Coaching, and other services rendered by Rocky Mountain Brain Integration LLC hinges on your honesty with us 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

Individual Responsibility Agreement *

I agree to the Individual Responsibility Agreement

I understand Personal Development Coaching is a self-reflective process intended to support personal transformation. I accept full responsibility for my participation, choices, and results.

to success failure;

Medical Wavier Agreement *

I agree to the Medical Wavier Agreement Below

By checking this box, I acknowledge that Rocky Mountain Brain Integration is not a medical provider and does not offer medical diagnoses, treatment, or prescriptions. I understand that any information provided by Rocky Mountain Brain Integration is not a substitute for professional medical advice, diagnosis, or treatment. I understand the risks associated with any activities or recommendations provided by Rocky Mountain Brain Integration and voluntarily assume these risks. I release Rocky Mountain Brain Integration, its employees, and affiliates from any liability for injury, loss, or damage that may result from participation in Rocky Mountain Brain Integration's services.

Copyright and Intellectual Property Protection Agreement *

I agree to 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 Brain 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 brain codes, code examples, and the full Brain Code Editor

Date

Signature *

Please Type Your Name Above, Then Click Submit Below