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Intake +
Terms & Agreements

Please read and complete the intake form below. Please read and sign the life coaching consent and waivers. 

Emotional Core Intake

Intake Form
Choose One Option
Check all statements that apply.

Life Coaching Consent and Waivers

This form covers coaching services given by Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength

Please read this form carefully.I hereby agree to the following: I understand that life coaching is a relationship I have with my coach designed to facilitate the creation/development of my best life, and I express how my coach can assist. I understand that life coaching is a comprehensive process that may involve all areas of my life and could include work, finances, health, relationships, education, activities and that deciding what to do in these realms is my responsibility. I understand that the information I give to Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength is confidential unless I state otherwise, in writing. However, I understand that if I report abuse, neglect or threaten to harm myself or someone else, necessary actions will be taken and my confidentiality agreement will not limit this capacity.  As a client, I understand and agree that I am fully responsible for my wellbeing during my coaching sessions, including my decisions and choices. I may discontinue my coaching sessions with Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength at any time.I know that coaching is not psychotherapy, counseling or any medical alternative. I understand that coaching is not a substitute for counseling, psychotherapy, mental health and will not use it in place of any form of therapy or medical advice. I agree I am well adjusted, mentally healthy and ready for coaching. It is my responsibility to consult my health care provider prior to participating in coaching with Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength. Should I choose not to consult my primary health care provider, I accept full responsibility & waive all rights to liability or any claims against Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength or any affiliated administrators, or employees. I release the organization or business named above from all liability, costs and damages which might arise from participation in the above named event or activity. I understand that some coaching sessions may include light touch or a Prayer Coach Service which is hereby acknowledged, I understand it will only occur with my permission.  I do hereby release and forever discharge Joelene Lemke, Kardia Reign LLC,  dba Recovered Core Strength their agents, employees, successors, and assigns, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named, none of whom admit any liability to the undersigned, but all expressly denying liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, which I now have or may hereafter have, arising out of or in any way relating to any and all injuries and damages of any and every kind, to both person and property, and also any and all injuries and damages that may develop in the future, as a result of or in any way relating to this coaching service.

I forever release Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength from any and all actions, claims or demands that I, my assignees, heirs, distributes, guardians, next of kin, spouse and legal representatives now have or may have in the future, for injury, death, or property damage, related to my participation in this activity or for the negligence or other acts, whether directly connected to this activity or not. I agree, the client would be responsible for attorney fees for all parties if a lawsuit is filed.I understand that I am responsible for the fees if I cancel less than 24 hours. Missed sessions will not be made up.I am choosing to participate in coaching services with Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength Any suggested Exercises, Meditation, Prayers or Reading Material is just a suggestion. It is my choice to perform or read any suggested material and I do them at my own risk.I have read and understood the contract as written here and agree to all terms by purchasing any sessions. 

Please check the boxes to confirm you have read and understand the statements below.

Thanks for submitting your information.

Pelvic Floor Intake

Pelvic / Post Pregnancy Intake Form
Have you ever had, been dignosed, treated for or currently experiencing the following:

Life Coaching Consent and Waivers

This form covers coaching services given by Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength

Please read this form carefully.

I understand that Kardia Reign LLC DBA Recovered Core Strength Fitness Coaching and/or Life Coaching is a partnership between me and the Coach.Fitness Coaching and/or Life Coaching is not a substitute for any individual medical diagnosis, treatment and/or evaluations or advice. If any advice is given, it is given in good faith and without prejudice and must be deemed appropriate by me, the Client. Kardia Reign LLC DBA Recovered Core is a provider of complementary care, exercise coaching and/or life coaching.

Joelene Lemke is not a licensed health care provider and does not engage in patient diagnosis or the practice of medicine. At this time my services are not covered by medical insurance.

By signing below I acknowledge and agree that all information listed in this contact is true and accurate.

My signature forever releases Kardia Reign LLC DBA Recovered Core Joelene Lemke from any and all legal liability both professionally and generally. Releasing  all actions, claims or demands that I, my assignees, heirs, distributes, guardians, next of kin, spouse and legal representatives now have or may have in the future, for injury, death, or property damage, related to my participation in this activity or for the negligence or other acts, whether directly connected to this activity or not. I agree, the client would be responsible for attorney fees for all parties if a lawsuit is filed.

I understand that Kardia Reign LLC  DBA Recovered Core exercises are for informational purposes. They are not a substitute for any individual medical diagnosis, treatment and/or evaluations. I am choosing to do these exercises in conjunction with a licensed physical therapist and or a licensed medical physician. I have been advised that at any time these exercises cause pain, or any other discomfort I am to discontinue them until I speak to my licensed medical Physician. I understand that by doing these exercises it does not guarantee any results. By signing below I acknowledge and release Joelene Lemke, Recovered Core Strength from any legal liability. 

Description of Exercise Appointments:

Exercise Coaching is a partnership (defined as an alliance, not a legal business partnership) between the Coach and the Client. It is designed to facilitate the development of educating and assisting in making safe and effective exercise programs for clients. 

INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM

Purpose and Explanation of Procedure:

I hereby consent to voluntarily engage in an acceptable plan of personal fitness training.  I also give consent to be placed in personal fitness training program activities which are recommended to me for improvement of dietary counseling, stress management, and health/fitness education activities. The levels of exercise I perform will be based upon my cardiorespiratory (heart and lungs) and muscular fitness. I understand that I may be required to undergo a graded exercise test prior to the start of my personal fitness training program in order to evaluate and assess my present level of fitness.

I will be given exact personal instructions regarding the amount and kind of exercise I should do. A professionally trained personal fitness trainer will provide leadership to direct my activities, monitor my performance, and otherwise evaluate my effort. Depending upon my health status, I may or may not be required to have my blood pressure and heart rate evaluated during these sessions to regulate my exercise within desired limits. I understand that I am expected to attend every session and to follow staff instructions with regard to exercise, stress management, and other health and fitness regarded programs. If I am taking prescribed medications, I have already informed the program staff and further agreed to inform them promptly of any changes which my doctor or I have made with regard to use of these. I will be given the opportunity for periodic assessment and evaluation at regular intervals after the start of the program.

I have been informed that during my participation in the above described personal fitness training program, I will be asked to complete the physical activities unless symptoms such as fatigue, shortness of breath, chest discomfort or similar occurrences appear.  At this point, I have been advised that it is my complete right to decrease or stop exercise and that it is my obligation to inform the personal fitness training program personnel of my symptoms, should any develop.

I understand that during the performance of exercise, a personal fitness trainer will periodically monitor my performance and, perhaps, measure my pulse, blood pressure, or assess my feelings of effort for the purposes of monitoring my progress. I also understand that the personal fitness trainer may reduce or stop my exercise program when any of these findings indicate that this should be done for my safety and benefit.

I also understand that during the performance of my personal fitness training program physical touching and positioning of my body may be necessary to assess my muscular and bodily reactions to specific exercises, as well as to ensure that I am using proper technique and body alignment.  I expressly consent to physical contact for the stated reasons above.

Risks:

It is my understanding and I have been informed that there exists the remote possibility during exercise of adverse changes including, but not limited to, abnormal blood pressure, fainting, dizziness, disorders of heart rhythm, and in very rare instances of heart attack, stroke, or even death. I further understand and I have been informed that there exists the risk of bodily injury including, but not limited to, injuries to the muscles, ligaments, tendons, and joints of the body. Every effort, I have been told, will be made to minimize these occurrences by proper staff assessments of my condition before each personal fitness training session, staff supervision during exercise and by my own careful control of exercise efforts. I fully understand the risks associated with exercise, including the risk of bodily injury, heart attack, stroke or even death, but knowing these risks, it is my desire to participate as indicated herein.

Benefits To Be Expected And Alternatives Available to Exercise:

I understand that this program may or may not benefit my physical fitness or general health. I recognize that involvement in the personal fitness training sessions will allow me to learn proper ways to perform conditioning exercises, use fitness equipment and regulate physical effort.  These experiences should benefit me by indicating how my physical limitations may affect my ability to perform various physical activities. I further understand that if I closely follow the program instructions, that I will likely improve my exercise capacity and fitness level after a period of 3-6 months.

Confidentiality And Use of Information:

I have been informed that the information which is obtained in this personal fitness training program will be treated as privileged and confidential and will consequently not be released or revealed to any person, to the use of any information which is not personally identifiable with me for research and statistical purposes so long as the same does not identify my person or provide facts which could lead to my identification.  Any other information obtained, however, will be used only by the program staff to evaluate my exercise status or needs.

 

Inquiries And Freedom of Consent: 

I have been given an opportunity to ask questions as to the procedures. 

I have read this Informed Consent form, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without inducement.

 

 

INFORMED CONSENT FORM FOR PHYSICAL FITNESS PROGRAM

General Statement of Program Objectives and Procedures:

I understand that this physical fitness program includes exercises to build the cardiorespiratory system (heart and lungs), the musculoskeletal system (muscle endurance and strength, and flexibility), and to improve body composition (decrease of body fat in individuals needing to lose fat, with an increase in weight of muscle and bone). Exercise may include aerobic activities (treadmill, walking, running, bicycle riding, rowing machine exercises, group aerobic activity, and other aerobic activities), calisthenic exercises, and weight lifting to improve muscular strength and endurance and flexibility exercises to improve joint range of motion.

Description of Potential Risks:

I understand that the reaction of the heart, lung, and blood vessel system to exercise cannot always be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart attacks. Use of the weight lifting equipment, and engaging in heavy body calisthenics may lead to musculoskeletal strains, pain and injury if adequate warm-up, gradual progression, and safety procedures are not followed. I understand that a personal trainer ( seller ) shall not be liable for any damages 

arising from personal injuries sustained by a client ( buyer ) while and during the personal training program. Client ( buyer ) using the exercising equipment during the personal training program does so at his/her own risk. Client ( buyer ) assumes full responsibility for any injuries or damages which may occur during the training.

I hereby fully and forever release and discharge personal trainer Kardia Reign DBA Recovered Core, Joelene Lemke , its assigns and agents from all claims, demands, damages, rights of action, present and future therein.

I understand and warrant, release and agree that I am in good physical condition and that I have no disability, impairment or ailment preventing me from engaging in active or passive exercise that will be detrimental to heart, safety, or comfort, or physical condition if I engage or participate ( other than those items fully discussed on health history form).

I state that I have had a recent physical checkup and have my personal physician's permission to engage in aerobic and/or anaerobic conditioning.

Description of Potential Benefits:

I understand that a program of regular exercise for the heart, lungs, muscles and joints, has many benefits associated with it. These may include a decrease in body fat, improvement in blood fats and blood pressure, improvement in physiological function, and decrease in heart disease.I have read the foregoing information and understand it. Any questions which may have occurred to me have been answered to my satisfaction.

This form covers coaching services given by Kardia Reign LLC DBA Recovered Core Please read this form carefully. I hereby agree to the following:

I understand that life coaching is a relationship I have with my coach designed to facilitate the creation/development of my best life, and I express how my coach can assist. I understand that life coaching is a comprehensive process that may involve all areas of my life and could include work, finances, health, relationships, education, activities and that deciding what to do in these realms is my responsibility. 

I understand that the information I give to Kardia Reign LLC DBA Recovered Core is confidential unless I state otherwise, in writing. However, I understand that if I report abuse, neglect or threaten to harm myself or someone else, necessary actions will be taken and my confidentiality agreement will not limit this capacity. 

As a client, I understand and agree that I am fully responsible for my wellbeing during my coaching sessions, including my decisions and choices. I may discontinue my coaching sessions with  Kardia Reign LLC DBA Recovered Core at any time. I know that coaching is not psychotherapy, counseling or any medical alternative. I understand that coaching is not a substitute for counseling, psychotherapy, mental health and will not use it in place of any form of therapy or medical advice. I agree I am well adjusted, mentally healthy and ready for coaching. It is my responsibility to consult my health care provider prior to participating in coaching with  Kardia Reign LLC DBA Recovered Core Should I choose not to consult my primary health care provider, I accept full responsibility & waive all rights to liability or any claims against  Kardia Reign LLC DBA Recovered Core or any affiliated administrators, or employees. I release the organization or business named above from all liability, costs and damages which might arise from participation in the above named event or activity. 

I forever release Kardia Reign LLC DBA Recovered Core from any and all actions, claims or demands that I, my assignees, heirs, distributes, guardians, next of kin, spouse and legal representatives now have or may have in the 

future, for injury, death, or property damage, related to my participation in this activity or for negligence or other acts, whether directly connected to this activity or not. I agree, the client would be responsible for attorney fees for all parties if a lawsuit is filed.

I understand that I am responsible for the fees if I cancel less than 24 hours. Missed sessions will not be made up.

I am choosing to participate in coaching services with Kardia Reign DBA Recovered Core Any suggested Yoga Poses, Meditation or Reading Material is just a suggestion. It is my choice to perform or read any suggested material and I do them at my own risk. I have read and understood the contract as written here and agree to all terms.

Coaching waiver:

This form covers coaching services given by Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength

Please read this form carefully.I hereby agree to the following: I understand that life coaching is a relationship I have with my coach designed to facilitate the creation/development of my best life, and I express how my coach can assist. I understand that life coaching is a comprehensive process that may involve all areas of my life and could include work, finances, health, relationships, education, activities and that deciding what to do in these realms is my responsibility. I understand that the information I give to Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength is confidential unless I state otherwise, in writing. However, I understand that if I report abuse, neglect or threaten to harm myself or someone else, necessary actions will be taken and my confidentiality agreement will not limit this capacity.  As a client, I understand and agree that I am fully responsible for my wellbeing during my coaching sessions, including my decisions and choices. I may discontinue my coaching sessions with Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength at any time.I know that coaching is not psychotherapy, counseling or any medical alternative. I understand that coaching is not a substitute for counseling, psychotherapy, mental health and will not use it in place of any form of therapy or medical advice. I agree I am well adjusted, mentally healthy and ready for coaching. It is my responsibility to consult my health care provider prior to participating in coaching with Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength. Should I choose not to consult my primary health care provider, I accept full responsibility & waive all rights to liability or any claims against Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength or any affiliated administrators, or employees. I release the organization or business named above from all liability, costs and damages which might arise from participation in the above named event or activity. I understand that some coaching sessions may include light touch or a Prayer Coach Service which is hereby acknowledged, I understand it will only occur with my permission.  I do hereby release and forever discharge Joelene Lemke, Kardia Reign LLC,  dba Recovered Core Strength their agents, employees, successors, and assigns, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named, none of whom admit any liability to the undersigned, but all expressly denying liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, which I now have or may hereafter have, arising out of or in any way relating to any and all injuries and damages of any and every kind, to both person and property, and also any and all injuries and damages that may develop in the future, as a result of or in any way relating to this coaching service.

I forever release Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength from any and all actions, claims or demands that I, my assignees, heirs, distributes, guardians, next of kin, spouse and legal representatives now have or may have in the future, for injury, death, or property damage, related to my participation in this activity or for the negligence or other acts, whether directly connected to this activity or not. I agree, the client would be responsible for attorney fees for all parties if a lawsuit is filed.I understand that I am responsible for the fees if I cancel less than 24 hours. Missed sessions will not be made up.I am choosing to participate in coaching services with Joelene Lemke, Kardia Reign LLC DBA Recovered Core Strength Any suggested Exercises, Meditation, Prayers or Reading Material is just a suggestion. It is my choice to perform or read any suggested material and I do them at my own risk.I have read and understood the contract as written here and agree to all terms by purchasing any sessions. 

Please check the boxes to confirm you have read and understand the statements below.

Thanks for submitting your information.

Pelvic Floor Intake
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