Date of birth
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Gender
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Occupation
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Have you completed a confidential questionnaire for a residential workshop you have attended with me in the past 18 months
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Your family, and how & where you grew up
(Please include the relative ages of any siblings)
Your education & career
Your current lifestyle – including exercise, diet, sleep, self-care
Your relationship status, history, duration and major issues during relationships?
How you describe your sexual orientation?
Do you have a spiritual practice or belief?
Do you have children?
If so, please give names and ages.
Have you ever been in therapy? If yes, please describe
Have you ever received outpatient or inpatient care for mental health issues, or been prescribed medication for an emotional issue? If yes please give details
Do you have any physical injuries or limitations?
Is a doctor treating you? If yes, please list conditions and treatments?
Are you currently taking any prescribed medication? If so, please elaborate
Do you have any history as the victim or perpetrator of violence, or the crossing of personal boundaries? If yes, please explain.
Have you ever been suicidal? If yes, please explain.
Have you ever experienced flashbacks or extreme fear about physical touch? Do you have any memories of physical, sexual, emotional or ritual abuse? If yes, please explain.
If you use recreational drugs or alcohol please state drug, frequency and amount per week
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What are / have been your addictions?
What is your biggest fear?
What has been happening in your life that led you to contact me for coaching?
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What would you like to get from coaching sessions?
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If you got what you wanted, how might this affect your life?
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What is blocking you from making the changes you want in your life?
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Can you think of any ways in which you might unconsciously sabotage yourself during the work we do together?
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Is there anything else I should know or you would like me to know?
What would you like to focus on during the first session?
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I understand the coaching offered by Ed is not designed for the rehabilitation or treatment of PSTD, complex PTSD or developmental trauma.
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(If you have suffered from trauma, PTSD, or any other mental health condition, it is essential that you give details on the form above. Moreover, if you have concerns about whether the workshop is suitable for you due to these conditions it is essential that you discuss this with Ed, and if appropriate seek the advice of a mental health professional.)
Though there may be therapeutic benefits, I understand that Ed is not a psychotherapist and the coaching he offers is not a substitute for psychotherapy or counselling.
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I understand that all sessions take place over Zoom at the link below, and that calls must be made from a private indoor location with video enabled and without a virtual background effect.
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edrooke.com/zoom
Password = roots
(please bookmark or take note of this link now so that you have it ready for sessions)
I understand and accept the following conditions for coaching with Ed
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- Sessions are 1 hour duration
- Sessions can be cancelled or rescheduled provided over 48 hours notice is given. Sessions cancelled or rescheduled with under 48 hours notice will be charged at the hourly rate.
- Once started blocks of sessions are non-refundable. This allows for deeper work by ensuring commitment to a full block before we begin working together.
- Ed's coaching hours are between 10.30 am and 6.00 pm on weekdays. His availability within these hours will vary on different days and can be seen at edrooke.com/schedule.
- Sessions can be scheduled at this link to suit your process. However, to ensure continuity, all sessions within a block must be used within 8 months of their purchase, after which any remaining sessions will be cancelled without refund.
- Any practical questions surrounding the sessions should be sent to ed@edrooke.com and Ed will do his best to respond within one or two working days. It will not be possible to have phone conversations between sessions, nor will it usually be possible to schedule an extra session at short notice (<48 hours).
- All sessions take place over Zoom at the following address edrooke.com/zoom, with the password; 'roots' (please bookmark or take note of this link now so that you have it ready for sessions)
If you have questions or are not able make any of these agreements please explain below;
