Client Information Form

Thank you for requesting my services. I am a Sports Performance Consultant and work with athletes at all levels and other performers outside of sports to help them overcome performance fears and blocks and reach their potential. I work remotely over Zoom or FaceTime in 50 minute sessions. I help individuals become aware of what’s stopping them from reaching their performance goals and then guide them to eliminate what’s generating their problems. I teach peak performance principles/skills as well as utilizing Somatic Experience, (SE), as a tool to help athletes of all ages to be able to recognize where they’re experiencing their fears and blocks in their body and how to calm themselves down and achieve peak performance. I hold a doctorate from the University of Massachusetts’ School Of Education that was awarded in 1983. I’ve been practicing as a Peak Performance Coach for over 40 years.

Email
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Client Contact Information
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Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Phone*
Athlete's Email
Zoom email 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 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 send me a payment link that I need to pay once the link is sent to me.
Policy 2*
- I must notify Dr. Goldberg 24 hours in advance if I need to cancel my appointment otherwise I'll be responsible for the session.
Policy 3*
- Yes, I understand that Dr. Goldberg is not a psychologist, counselor or therapist. He does not diagnose conditions or prescribe treatments. He refers those individuals with mental health issues to qualified professionals.
Policy 4*
- I understand that goals will be mutually identified as part of the assessment and clients have input in that process. Homework will be assigned to clients and commitment to the process is essential for a successful outcome.
Policy 5*
- I understand that Dr. Goldberg does not hold any license and does not except any insurance payments
Policy 6*
- 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 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 7*
- I understand that Dr. Goldberg will not release my records without my written permission.