In that spirit, by purchasing coaching services from your Health and Wellness Coach, you confirm that you have read and agree to each statement and that you wish to proceed: *

I understand that the coaching services I will be receiving from my Coach are not offered as a substitute for professional mental health care or medical care and are not intended to diagnose, treat or cure any mental health or medical conditions. I also understand that my Coach is not acting as a mental health counselor or a medical professional.

I understand that coaching is, at present, an unregulated industry and that my Coach is not licensed by the State of Pennsylvania or any other state. I also understand that for all legal purposes, the services provided by my Coach will be considered to be provided in the State of Pennsylvania.

I understand and agree that I am fully responsible for my well-being during my coaching sessions, and subsequently, including my choices and decisions.

I understand that coaching is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy.

I understand that all comments and ideas offered by my Coach are solely for the purpose of aiding me in achieving my defined goals. I have the ability to give my informed consent, and hereby give such consent to my coach to assist me in achieving such goals.

I understand that to the extent our work together involves career or business, my Coach is not promising outcomes included but not limited to increased clientele, profitability and or business success.

I understand that my Coach will protect my information as confidential unless I state otherwise in writing. If I report child, elder abuse or neglect or threaten to harm myself or someone else, I understand that necessary actions will be taken and my confidentiality agreement limited in this capacity. Furthermore, if my Coach is ordered by a court to provide information or to testify, she will do so to the extent the law requires.

I understand that the use of technology is not always secure and I accept the risks of confidentiality in the use of email, text, phone, Skype and other technology.

I hereby release, waive, acquit and forever discharge my Coach, any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of acts or omissions by myself or by my Coach as a result of the advice given by my Coach or otherwise resulting from the coaching relationship contemplated by this agreement. I further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents.

I ACKNOWLEDGE THAT I HAVE READ THIS DOCUMENT IN ITS ENTIRETY AND FULLY UNDERSTAND IT’S CONTENT. I AM AWARE THAT THIS IS A WAIVER AND RELEASE OF LIABILITY. I represent and warrant I am signing this document freely, willfully and not under fraud or duress, and understand its content and cannot be modified orally. *

I ACCEPT THE TERMS AND CONDITIONS ABOVE

I DO NOT ACCEPT THE TERMS AND CONDITIONS ABOVE

Name *

First Name

Last Name

Date *

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I will pay for services through invoicing via email.

I understand that services can be paid for via cash, check, credit card and/or direct from your checking account.

I understand that a 10%/day late fee will be applied to late invoices.

I understand that one hour sessions are at the rate of $85/hour

I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE FINANCIAL AGREEMENT TERMS ABOVE. I AM AWARE OF MY FINANCIAL RESPONSIBILITY FOR THE SERVICES PROVIDED TO ME BY MY WELLNESS COACH. I represent and warrant I am signing this document freely, willfully and not under fraud or duress, and understand its content and cannot be modified orally. *

I ACCEPT THE TERMS AND CONDITIONS ABOVE

I DO NOT ACCEPT THE TERMS AND CONDITIONS ABOVE

Name *

First Name

Last Name

Date *

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