Personal Coaching with Jordan Bach
Thanks for your interest in working with me privately.

This application serves as my first introduction to you, so please answer the following questions thoughtfully and in detail. It usually takes about an hour to complete the form.

If I feel we might be a good fit, I’ll reach out to schedule a time to talk more about what a coaching agreement with me entails.

Your information will be kept safe & confidential.
Begin
 
What's your full name? *

 
What name should I call you by? *

 
How did you find me? *

Examples: your YouTube video on how to gain clarity, I started following you on Instagram, my friend Beyoncé told me about you, et cetera.
 
What's your telephone number? *

 
What's your mailing address? *

 
How old are you? *

 
What's your birthday? *

 
Your current medical treatment

 
What medical professionals are you working with right now, if any? *

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

Please leave name below, or write "None."
 
What, if any, psychoactive substances (legally prescribed or otherwise) do you regularly consume? *

A psychoactive substance is a chemical substance that changes brain function and results in alterations in perception, mood, or consciousness.

Notable and popular examples of psychoactive substances include antidepressants, ADD medication, tobacco, alcohol, caffeine, and cannabis.

Please note substance and frequency, or write "None." If you have (or have wondered if you have) an unhealthy relationship with a substance, let me know.
 
Release of Relevant Treatment Information *

In the context of my coaching relationship with Jordan Bach of The Bach Book LLC, I authorize him 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 Jordan Bach and that our work is not therapeutically based. I understand, and agree, that Jordan Bach does not represent himself 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 I ask you, don't give me the "right" answer. Give me the truth.
 
Up until this point, what has motivated you in life? *

 
What is your bigger vision for your life? *

This isn't meant to be a declaration of your destiny. It's a peek into your dreams. Maybe start by asking yourself: "What is my heart calling me to do with my life? What are the longstanding dreams I've dreamt for my life? What would I regret not attempting to accomplish by the end of this life?"
 
If you experience "realistic" growth in the next 3 months, what would that look like? *

I used quotation marks to emphasize that this is a short-term vision. Tell me what you think is possible in three months' time if you made major breakthroughs and courageously took bold steps toward the life you want.
 
What would it feel like to accomplish that? *

Tell me what accomplishing these goals will do for you. Don't say, "I'll be happy!" Instead, visualize what it would be like to be have already achieved these goals. How do you feel now? How has your mind, body, and spirit shifted? Be specific.
 
What's holding you back right now? *

Be honest about the blocks, the challenges, and the fears you're facing.
 
What has it cost you not having what you want? *

How has living at the level you're currently at impacted you negatively?
 
Let's go deeper. 

I work with inspired and inspiring people. Let's talk a bit about the way you think about yourself, other people, and the world around you.
 
How are you a truly inspired person? *

 
How are you a truly inspiring person? *

 
Here's my definition of spirituality: *

Spirit is the psychological context within which you live your life. When someone else says, "I like your energy," they're talking about your spirit. Your spirit, or your energy, is simply the quality of the thoughts you consistently think about yourself, other people, and the world.

Spirituality is the awareness of your energy and the awareness of your own power to change it.

Do you get what I'm saying?
 
What are your spiritual beliefs? *

What do you believe to be true about yourself, other people, and your place in the world?
 
Which spiritual tools or practices are helpful for you? *

What helps you shift your energy (your thoughts) from negative to positive?
 
Which term do you feel most comfortable using in conversation? *


 
Almost done…

Breathe deeply.
 
Are you willing to make a significant investment in yourself? *

Coaching with me is a significant investment of your time, money, and energy. You'll get from it as much as you give. Are you willing to stretch out of your comfort zone? Comments optional.
 
How is your financial health? *

Is money a source of anxiety or fear? Are you in debt? No need to get into the nitty gritty—but how's your life looking money-wise right now?
 
How will you know if you're receiving value from working with me? *

What outcomes would make this investment worth it?
 
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.
     
 
Release of Liability *

The information contained within www.thebachbook.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 The Bach Book LLC or Jordan Bach 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 The Bach Book LLC or Jordan Bach liable for any actions that you take. You agree not to hold The Bach Book LLC, or any employees of The Bach Book 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 The Bach Book LLC or Jordan Bach.

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 counselling 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 The Bach Book LLC or Jordan Bach. 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 The Bach Book LLC or Jordan Bach 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 The Bach Book LLC or Jordan Bach be liable for any incident or consequential damages resulting from use of the material.

You shall indemnify The Bach Book LLC and its associates, in the event of any such claim, including but not limited to any claims made against The Bach Book LLC or Jordan Bach, 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).

The Bach Book LLC, Jordan Bach, and www.thebachbook.com reserves the right to refuse service for any reason.

Results are not guaranteed. The Bach Book LLC, Jordan Bach, and www.thebachbook.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.
     
Thank you for your responses.

If I feel we might be a good fit, I’ll reach out to schedule a time to talk more about what a coaching agreement with me entails.

I hope you gained some measure of clarity simply by taking the time to answer these questions honestly.
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