VIVID Relationships: Client Information Form
VIID
Relationships
Coaching Client Information Form

Please complete all required fields below. This information helps your VIVID Relationships provider prepare for your sessions and ensure the best possible experience.

General Information
Personal Details
Contact Information
Background
Health & History

Please include any relevant medical or mental health history, including diagnoses (whether self-identified or diagnosed by a professional), as well as any prescribed or over-the-counter medications.

Please include any previous or current work with coaches or therapists.

Payment & Policies

If you are responsible, please type your name. If someone else is responsible, include their name and phone number. The responsible party must agree to all payment policies.

You are financially responsible for all services provided. VIVID Relationships (Texas Relationship Therapy PLLC, as listed on billing statements) does not bill insurance or any third-party payers. We do not provide documentation beyond receipts for payments made. Payment is due at the time services are provided or in the case of a late cancellation or missed session.
If you have purchased a pre-paid coaching package and choose to discontinue services, a 50% refund will be issued for any unused sessions based on the discounted package rate. All pre-paid sessions must be used within one calendar year of purchase.

A minimum of 24 hours' notice is required to reschedule or cancel an appointment. If proper notice is not given, the full session fee will be charged to the card on file.

For missed couples sessions, each participant may be charged their portion of the session fee. This agreement may be used in the event of a payment dispute.
Additional Information

Please be as specific as possible. If referred by a physician, client, coach, or therapist, please include their name. If through media, please specify the program, publication, or event.

This contact will only be used with your consent or if there is a concern regarding your immediate safety.

Your information is private and will only be reviewed by your VIVID provider.

Information Submitted

Thank you! Your information has been received.
Your VIVID Relationships provider will follow up with next steps.