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Counseling, Certified Life Coach
& Motivational Speaker
Annmarie J
Holness, LMSW
NY State
License: 092992
Certified Life Coach
Member of NASW, DAV & American Legion
Tel: (631) 223-8638
T4NewPerspective@gmail.com
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Helpful Forms
If you're a new client, please complete the following forms and
bring them to your first therapy session.
Life Coach Forms
• Client Action
Sheet
• Client Intake
sheet
• Life Coach
Contract Agreement
Counseling Forms
• Client Psychotherapy
Intake Form
•
Limits of Confidentiality/Therapy Cancellation Policy
For Counseling clients only:
If you would like me to coordinate care with another provider (for
example, your psychiatrist, primary care physician, etc.), complete
this form to authorize release of psychotherapy information:
• Authorization to
Disclose Information Form
Note: To download Adobe Acrobat Reader for free,
click here.
Privacy & Policy Statement
Confidentiality & Privacy Policy
The law protects the relationship between a client and a Life coach,
and information cannot be disclosed without written permission.
Exceptions include:
• Suspected child abuse or dependent adult or elder abuse, for which
I am required by law to report
this to the appropriate authorities immediately.
• If a client is threatening serious bodily harm to another
person/s, I must notify the police and inform
the intended victim.
• If a client intends to harm himself or herself, I will make every
effort to enlist their cooperation in
ensuring their safety. If they do not cooperate, I will take
further measures without their permission
that are provided to me by law in order to ensure their safety.
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