What is Kingdom Wellness Center?

Kingdom Wellness Center helps individuals grow through wellness support, mentorship, life guidance, and faith-based encouragement.

Community Referral Consent Form

Kingdom Wellness Life Coaching - Personal Development and Goal-Setting Support

Purpose

This form allows your community organization to refer you to Kingdom Wellness Life Coaching for personal development and goal-setting support. Coaching is not medical, mental health, or therapeutic treatment.

Client Information

Full Name *

Date of Birth *

Email *

Phone *

Community Organization Name *

Organization Phone *

Referral Consent

I, the undersigned, consent to being referred to Kingdom Wellness Life Coaching by my community organization. I understand that:

Coaching is for personal growth and wellness, not medical or mental health treatment.

I may choose whether or not to participate in coaching services.

Kingdom Wellness Life Coaching is independent; the community organization is not responsible for the outcome of coaching.

My personal information (name, email, phone number) may be shared with Kingdom Wellness only for the purpose of initiating coaching services.

Specific Needs / Notes (Optional)

Only relevant info for coaching (e.g., accessibility, preferred contact method)

Client Acknowledgment & Signature

By signing below, I agree to the referral and consent to share my contact information with Kingdom Wellness:

Type Your Full Name (Signature) *

Date *

Community Organization Representative

I confirm that the above client has consented to this referral:

Representative Name *

Title/Role *

Type Your Full Name (Signature) *

Date *

Privacy Notice (2026 Compliance): All information shared is confidential and stored securely according to current data protection standards. Digital copies are encrypted if shared via email or online platforms. This form is valid for phone, video, or in-person coaching.