Crowned by Virtue Inquiry Form

Please be detailed with this form so that we can assess root challenges as we are preparing to provide you services. Please be mindful to include the following: Information regarding any unresolved life hurts and experiences, childhood issues, teenage issues, young adult and adult issues. This will help ensure that you receive the most effective services. The more detailed you are the more effective your services will be.
First Name
Last Name
Age
City
Address

Street Address Line 2

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
What is your Time Zone?
Phone Number
Format: (000) 000-0000.
FemaleMale
SingleMarriedDivorcedWidowed
Occupation
Employer
Emergency Contact: Please list name, phone number, and address
Format: (000) 000-0000.
Referred by
Mentoring (3 month commitment)45 Minute Strategic Consultation60 Minute Coaching Session
Concerns: What reasons are you seeking services?
Please describe any significant events that occurred during the time of or since the concern started
Are you having difficulty or stressors currently?
Are there any specific behaviors, actions, or habits that you would like to change?
Inadequacy/InsecurityFear/TerrorAnxietyRejectionAbandonmentHumiliationBetrayalAnger/RageGuiltShameHopelessnessHelplessnessFeeling StuckCannot hear God for InsightLow self-esteemPerfectionismOther
Medical History
List any medical conditions, mental illness, addictions or hospitalizations you have had.
Please list any trauma you experienced recently or in general (Ex. Covid-19, death, financial hardship, racial injustice issues, etc.)
List any additional triggers, frustrations, or challenges you have
Please list any generational curses in your family that you are aware of ie. (depression, domestic violence, sexual sin, etc.)
Please indicate the days and times generally work best for you regarding service. Services generally take place 5:00 PM-8:00 PM on Mondays, 6:00 PM-8:00 PM Tuesday-Friday, and 12:00 PM-2:00 PM on Saturdays.
Crowned by Virtue Mentoring and Coaching reserves the right to cancel my services if needed
Release of Liability Waiver
Please read and acknowledge understanding by you signature

Waiver: In consideration of being able to participate in any services provided by Crowned by Virtue, I for myself, my heirs, personal representatives or assigns, hereby release, waive, discharge, and covenant not to sue or hold liable Mercedes Carr, Crowned By Virtue, nor any assigned sponsors, speakers, partners, contractors, affiliates, or any entities connected to these persons, business, or organizations for services provided through Crowned by Virtue.

I acknowledge and understand that the information provided by Mercedes Carr cannot replace or substitute the services of any professional personnel including medical, psychological, financial or legal and none of the information should be confused as such. Neither Mercedes Carr, nor any assigned sponsors, speakers, partners, contractors or any of their affiliates will be liable for any direct, indirect, consequential, special, exemplary or other damages to the Client, Client’s family, life situations, or Client’s business including economic loss, that may result from participation in the Program or from the use or inability to use the materials, information or strategies communicated through the Program.

I acknowledge and understand that the Client (person/s receiving services and or guardian), alone are responsible and accountable for the decisions, actions, and results in life, and by their participation in this Program, they agree not to attempt to hold Mercedes Carr, Crowned by Virtue, or any entities connected to theses persons, business, or organizations liable for any decisions, actions or results that the client may make or experience in your family, business, ministry or life due to your participation in this Program at any time, under any circumstances.

Please Type full name for acknowledgement
This is a fill in the field. Please add appropriate blank fields and text.
Should be Empty:

Medical History

Release of Liability Waiver