COACHING REGISTRATION FORM | professionalhealth

top of page

Professional Health Consulting, LLC

Online Therapy with a Licensed Psychologist

Serving adults in North Carolina and Florida through secure telehealth

Dr. Elizabeth Jenkins, PhD

Licensed Psychologist

Providing online psychotherapy in North Carolina and Florida

HOME
ONLINE THERAPY
PROFESSIONAL HEALTH
- PROFESSIONAL HEALTH
- Disruptive behavior
ABOUT DR. JENKINS
FAQs
CONTACT
BLOG

Use tab to navigate through the menu items.

PHC Professional Health Evaluation & Coaching Pre-Enrollment Form

Please complete the following information form prior to your first professional health coaching visit.

Please note that PHC professional health evaluation & coaching is not designed to address mental health difficulties. PHC professional health evaluation & coaching is intended to assist you in achieving success in the workplace. It is not psychotherapy, and, as your professional coach, Dr. Jenkins is not serving in the role of a clinical psychologist. If we determine that your are experiencing a mental health concern, Dr. Jenkins will work with you to determine whether engaging in psychotherapy prior to or instead of coaching or in addition to coaching would be appropriate.

If you are seeking psychotherapy, please do not submit this form. Instead, please contact Dr. Jenkins by providing your name, number, and a brief description of the service you are seeking on our Information Request Form. You will generally get a return call within 3 business days. *

This site is not monitored 24/7 and the forms on this site should never be used in an emergency. If you are experiencing a life-threatening emergency, please call 911 or present immediately to the nearest emergency room.

First Name

Last Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Phone

Email

Occupation * Required

Physician

Nurse

Physician Assistant

Dentist

Pharmacist

Veterinarian

Practice Type * Required

Academic medicine

Private practice

Group practice

Hospital practice

Other: (describe below)

Leadership Role: * Required

Physician Executive (Dean, CEO, Department Chair, etc.)

Nurse Executive (Dean, CEO, Department Chair, etc.)

Dentist Executive (Dean, CEO, Department Chair, etc.)

PA Executive (Dean, CEO, Department Chair, etc.)

Pharmacist Executive (Dean, CEO, Department Chair, etc.)

Mid-level Management Leader (Division Chiefs, Office Manager, Section Head, etc.)

None of the above/NA

Type of Coaching Requested: (select all that apply)

Professionalism Coaching

Executive/Leadership Coaching

Coaching for Skill Development

Coaching Focus: * Required

Career Development

Resilience

Impairment in the workplace

Burnout

Team dynamics

Conflict Management

Distressed behaviors

Other (Please describe)

How were you referred to PHC for coaching? (select all that apply)

Hospital Leadership/Administrator, EAP

State Medical Board

State Physicians Health Program

Lawyer

Self-referral

Colleague

Found on our web page

Other: (describe below)

Is your coaching a requirement for your professional role? * Required

Yes

No

Please provide the contact name, email, phone number, and mailing address for the leader/individual who referred you to the coaching program. If you were not required, please respond - NA.

Type your name as a signature giving us permission to contact you and schedule your first coaching session:

Select a date * required

Thank you for completing this information prior to our initial visit

bottom of page