Client Information Form

Client Contact Information
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Mobile Phone
Athlete's Email
Skype name or FaceTime contact number
Date of Birth
MM slash DD slash YYYY
Your Sport Information
Coach's Name
First Last
Coach's Phone
Reason
History
Parent/Guardian Contact Information
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent Home Phone
Parent Office Phone
Parent Cell Phone
Parent Email
Policy 1*
Please review Dr. Goldberg's policies. If the athlete is under 18, this section must be completed by the athlete's parent/guardian.
- I understand that Dr. Goldberg will charge my credit/debit card after each 50-minute session.
Policy 2*
- I understand that sessions will be held via Skype/FaceTime, Dr. Goldberg will contact me at the agreed-upon time, and I must notify Dr. Goldberg 24 hours in advance if I need to cancel my scheduled appointment. I understand that my credit/debit card will be charged for the session if the cancellation is not completed within the 24-hour time frame.
Policy 3*
- Yes, I understand that Dr. Goldberg is not a psychologist. He does not hold any license and does not accept insurance.
Policy 4*
- I acknowledge that Dr. Goldberg is not responsible for any injury, harm, or damage arising from his provision of services to myself or my child. I, individually and as a parent or legal guardian of my child hereby agree to release and hold harmless Dr. Goldberg from any and all claims arising from his services.
Policy 5*
- I understand that Dr. Goldberg will not release my records without my written permission.
Session Recording Permission*
- I agree to have Dr. Goldberg occasionally record my session so that he can review it himself or confidentially with a professional colleague to assist me or my child in the most effective way possible.
- I do not want any of my sessions recorded.
Name
This field is for validation purposes and should be left unchanged.