Life Coaching Intake Form to Print!

kindly Write out your concerns which sessions you request and Call us to Fax it in or Mail it:

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~Professional Life Coaching Advice Services Available~


Statement of Informed Consent

Kindly Print & Fax or Mail to: 

The Holy Spiritual Order of Shams A Nuwaubian Moor Organization

Mr. Shamsuddin A. Abdul-Hakim Bey, M.S.
Primary Life Coach
Student of Mental Health, Peer Counseling Specialist
President / Founder - C.E.O., C.F.O.

C/o 1600 Sedgwick Avenue - Bronx, N.Y.S. Republic


Dir.: 1-347-584-7439 / V.Fax.: 1-347-431-7437

As An Outside Optional Alternative Additional Service We Have These

Earn $25.00 for Any Assistance with our Services or Referral Sign ups per client

All Services are now available at a $114.99 sign up fee, then $55.00 monthly!

 Sessions for Monthly Rate 5 hours Daily by Conference Call


Other Service Outlets for Holding Life Coaching Sessions 

By Phone, Email, Messenger, or In Our Chatroom

With A Special Code, Username and Password to Secure Confidentiality

Sometimes Perhaps On Location

Weekend Group Sessions of 3 hours straight or 2 Days 1 1/2 hours Individual each day of Life Coaching Advice

Saturdays & Sundays


All Services are now available at a $114.99 sign up fee, then $55.00 monthly!


Session 1 hour Daily for a Week by Phone or Online

Life Coaching Advice with Concerns, Problems, Issues, Finances, More!

Must Pay in Advance for Appointments

We Must Agree Here When Sessions Will Be Held

This Entire Document Constitutes the

Statement of Informed Consent

I_________________________________________________hereby understand, acknowledge, give consent  or consent is given on behalf of this client being the legal guardian of the client by____________________________________________ that the Life Coaching I will receive from Mr. Shamsuddin A. Abdul-Hakim Bey, M.S. Primary Life Coach Student of Mental Health, Peer Counseling Specialist will consist of:

Holistic Advice
We use every possible method and technique to help you reach a solution that will better your life. Once we start, we don't stop until you feel comfortable being able to cope and better manage your situation.

Herbal Remedies
We research natural foods, vitamins, minerals, and nutrients to go with exercises as alternative means to a better living. Our constant research keeps us updated on alternative remedies, although they may not be actual cures.

Networking & Brainstorming
We develop contacts and work in chat rooms for group, and individual sessions designed to give you and others empowerment beyond a 1-person approach. The methods we use are based upon the traditional 12-step approach, and more!

Important Notice:

Kindly note, before we can begin a session we must fill out and complete a basic application of assessment. We offer a 30 day trail period with the initial down payment which is to ensure that clients have a chance to get familiar and comfortable with the effectiveness of our services.Therefore it is vitally important that you call us before engaging any of our services. We will have to hold ourselves blameless and not responsible for anyone not following this basic instruction, or any of our Professional Life Coaching instructions. Remember this is a disclaimer stated to you, and everyone using our services in advance!

Why Our Life Coach?
With his insight and over 17 years of combined education and experience, we're able to effectively help you cope with life's difficulties, problems, and challenges. 
Unlike traditional life coaches, our remedies use a holistic networking approach to answer your problems, challenges, and difficulties with daily living!
This approach allows our life coach to gain collective help from your peers and other professionals for more a more personalized, efficient, and effective approach. If you feel for any reason that our services are not ligitimately effective in being able to help advise you in any way whatsoever, you are entitled to a refund paying us nothing after the first 30 days, and in part according to the extent of our satisfactory services to you thereafter as noticed by your continuation in our services up to the point of cancellation or dissatisfaction! 

Mr. Shamsuddin A. Abdul-Hakim Bey says that the Purpose for His Education in Graduate School and Beyond is:

The primary purpose for me obtaining 2 Bachelor of Arts degrees one in Sociology the other in Psychology at the City College of New York, CUNY and then wanting to go further in graduate school is to obtain my M.S. degree in Mental Health Counseling as a Specialization student; with International Counseling, and Academic Honors awarded by Chi Upsilon Chi, and Chi Sigma Iota at Capella University Minneapolis Minnesota is in order to help draw pathways for others. Further, I would like to commit myself out of this passion to be able to personally contribute to the upliftment of black people and other minorities, as well as other disadvantaged, impoverished people in society who have mental or other social problems causing dilemmas in their lives. I personally feel and realize that if I'm able to reach the highest point of my own personal peak, then I will be in a much better position to do more good to bring up other people with me.

The population(s) we / he serves and why:

It's my intention to not only aid people to alleviate their condition of crisis but to enrich their lives and lifestyles. Changing their lives socially and mentally is the beginning to bringing people out of poverty and despair. I look at the world around me, and I see that it's my people who have the least. While prisons are continuing to be built and education is less valued than layoffs, crime, suicide, homicide, drug addiction, and unwanted pregnancy are pervasive. There needs to be a call to enlightenment and more contribution to social and psychological benevolence for all.
We Cater to All Members of Society Without Exclusion to Any

As A Pan African Nuwaubian Cultural Activistic Organization!
ALL Faiths, Creeds, Cultures, Denominations, Beliefs ALL Are People
Welcome we hold No bias of any kind against anyone whatsoever, if we are not able by any means in our judgment to offer services to someone we will try to make reasonable accommodations to refer that person to another Life Coaching Advisor who we feel is more suitable and capable.

What is the methodology of Life Coaching being offered:

Life coaching advice to some is a kin to other forms of traditional counseling. Life coaching in fact some may think utilizes almost the same techniques of traditional counseling. In fact life coaching advice in some respects may have in part been derived out of the patterns, techniques, and methodologies of similar and traditional forms of counseling. With life coaching advice to make things more clear it can be perhaps defined as a solution focused approach, or goal oriented approach and / or as well.  Holistic advice can very well be a key element to life coaching advice, in that life coaching advice per say is dedicated to whatever may work for a client without being treatment, therapeutic oriented. Life coaching advice by its very term is meant to help or coach an individual as to how they may be guided to reach a solution of self – discovery in dealing with almost any issue, problem, or concern.  Life coaching advice as a holistic approach helps an individual understand or be provided with such suggestions, as to explore what may work as a life advice solution or what may not work at all, it is a guide using various different points of views to help a person, couple, family, or group of people.  Life coaching advice is designed to help empower an individual toward being able to personally find meaning, purpose, underlying factors, and a means of overcoming whatever challenges life may bring.

Life coaching is not meant nor intended holistically or otherwise to be a treatment, or progressive form of therapy.  Life coaching advice is just what it states that it is advice, not clinical counseling. For life coaching advice to be an acceptable non – license required kind of profession, it in a sense has the focal point to provide just advice, especially in and of the moment  not prolonged or ongoing followings of clients. If an individual or any group of people need extensive therapeutic workings through to deal with an issue professionals of those fields should be sought as preliminary to life coaching advice, or it can sometimes be used in conjunction with other forms of more traditional treatment and therapies. 

As life changes so does the orientation, answers, life coaching advice for any specific situation change from moment to moment, and day to day. Life coaching advice is designed to deal with the various differing aspects of issues, and that affect people often basically, and how, and whereas to how people may want and need to be guided, because the situation may not be clear entirely alone.  Life coaching more meaningfully then is the process of brainstorming at times with individuals, and people to find whatever works best for any given situation at all.

Ethically with any life coaching advice that may be given, it follows basically the same procedural protocols as other forms of alternative clinical professional counseling. Ethically, life coaching entails confidentiality, informed consent to services, protection from harm in any way, and honesty in ways that it does not compromise dignity, and the freedom of making choices for the individual person that are progressively productive, not destructive or so forth.  Professionals who give life coaching advice may not need to be licensed in some places, but they must be mindful to adhere to the same basic ethics as other professionals who do counseling of sorts, wherever they may be. The main thing to know about almost anyone giving life coaching advice is that though they may be as alternative as the field of chiropractors, spiritualist, or holistic remedy professionals of alternative practices is that with life coach advisors there are still mandated, and recognized ethical standards of procedures.  

It is understood that with the services offered:

Hours Are Subject to Change With or Without Notice Due to Unforeseen Circumstances We May Encounter Now or Later As Stated Here in Advance!
We Are Sorry for Any Inconvenience and If There Is Any Problem or Emergency - Please Feel Free to Contact Us for A Consultation Appointment Regardless by Phone or Email, or Both!
We Are Sorry and Thank You Again!

Other Service Outlets for Holding Life Coaching Sessions are again

by Phone, Email, Messenger, or In Our Chatroom

Sometimes Perhaps On Location.
For More info.:





If A Dyer Emergency Call 911

Service Area:

Bronx | Brooklyn | Manhattan, Queens | Staten Island, Worldwide

Our Main Headquarters for service information is:
Call us in Bronx, New York,  toll free at 1 (347) 928-8804 for networked life coaching
and peer counseling services that effectively help you live a better life.

Our expected compensation which is due, and subject to change with or without notification to anyone is this:
We are pleased to accept PayPal for our affordable inexpensive services. Let us recommend a package that may be right for your needs. Our packages are conveniently priced monthly at: All Services are now available at a $114.99 sign up fee, then $55.00 monthly 1 hour daily individual sessions, 3 hours straight Group Sessions or 2 days 1 1/2 hours Individual each day Saturdays & Sundays weekend  sessions, and our 5 hour daily monthly group sessions, this price for our monthly sessions include services we provide for special cases as well.                   
As Another Pertinent Optional Alternative Service We Offer:

Absolutely Required For Everyone

Write A Description of Your Concerns


Please Include For Client Information Name Age Date of Birth, Address(es), Phone Number(s), Email Address(es) As Well Any and All Emergency Contact Details Include Also the Time and Type of Desired  Service Sessions Morning Sessions or Evening Sessions With Any Other Pertinent or Special Information that

May be Necessary



Print Name(s):                                                                                                                      Signature(s):

Client Agrees to All of these Terms:                                                                                 Date & Time:_______________________________________________________

_____________________________________________________________________      __________________________________________________________________

_____________________________________________________________________      __________________________________________________________________

_____________________________________________________________________      __________________________________________________________________

For Office Coded Use Only Here, Client(s) Do Not Write Here Please, Thank You!

Officially Agreed to by Staff Members:                                                                               Date & Time:______________________________________________________

______________________________________________________________________      _________________________________________________________________

______________________________________________________________________      _________________________________________________________________

______________________________________________________________________      _________________________________________________________________

Office Assigned

Username:_____________________________________________________________     Password:________________________________________________________



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Special Services


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As Outside Alternative Optional Additional Services We Offer these Business Links: