fill out and submit consent form

Please fill out the following information prior to your Relationship Transformation Session

First name

Last name

Birthday

Month

Day

Year

Phone

Address

Are you currently receiving mental health treatment?

I understand that: Serena Denmark is not an MD, psychologist, or licensed family therapist. All services provided by Serena Denmark are restricted to education, coaching and mentoring.

I understand that Serena Denmark does not treat, diagnose, hospitalize, or prescribe drugs nor does she do any services which require a license. I understand that if I need these services, I am advised to seek them from properly licensed practitioners.

In no circumstances am I advised to discontinue or ignore treatment advice from licensed professionals.

I am the person most responsible for my own health and well being. Should I be uncomfortable with any suggestions made, I am free to disagree and refuse suggestions and seek a better solution from within my own frame of reference.

I understand that it is common to experience fatigue and/ or greater need for rest after coaching. It is sometimes common to experience a full range of emotions in the days following coaching.

I am an active participant in my coaching experience and see myself as a partner in the transformative nature of this process.

I understand that all information is confidential unless the release of such information is required by law. Such cases include knowledge of child abuse or neglect, serious risk of imminent danger to self or others, knowledge of a felony.

Serena's commitment to you: I will use my expertise to facilitate the changes that are mutually agreed upon to be in your best interest in the shortest time possible.

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