Confidential Intake

General information about you.

First name

Last name

Email

Date of Birth

Phone

Disclaimer & Waiver

I certify that I am over18

I have voluntarily elected to receive coaching and the nature and purpose of this service have been explained to me.

I understand that coaching can be used to help me focus and achieve the outcomes I desire including but not limited to improved confidence, heightened self-awareness, better relationships, clarity of purpose, goal attainment, balance, and improved communication.

I understand that I am a partner in the coaching process and that I have the right to agree or disagree with any of my coach's recommendaions.

I recognize there are no guaranteed results and that independent results are dependent upon many factors including but not limited to networks, mindset, lifestyle, and habits.

I understand that if the coaching relatioship isn't working for me it is my responsibility to say something so the coaching methods can be adjusted.

I understand that progress will be tracked periodically, and at the end of the commitment period my coaching outcomes and progress will be evaluated.

I understand that payment is due prior to my scheduled coaching appointment.

I understand that this agreement is for coaching, not therapy.

I understand that coaching cannot deal with issues such as clinical depression or clinical anxiety and that these issues must be dealt with by a physician or licensed mental health professional.

I understand that my coach will not diagnose or treat any medical or psychological conditions.

I understand the difference between a coach and a therapist and I will get appropriate professional help for any mental health issuses.

I understand that because coaching is not a medical treatment, insurance will not cover the cost.

I have read and understand the coaching disclaimer and waiver. My signature below indicates that I have read this agreement carefully and understand its contents. I agree to release, waive and forever discharge all liability toward my coach, any agents, successors, executors, heirs and employees from any claim, suit, action, demand or right to compensation for damages I have or claim to have as a result of the advice I receive from my coach or from the coaching relationship. If I have any questions or concerns about this waiver I will ask my coach to adress them before I sign.

Your Signature

Confidentiality Agreement

I understand that all information obtained in the course of my coaching services are confidential unless there is a compelling professinal or legal reason for its disclosure.

I understand that my coach will disclose confidential information without a specific release as required by law or if the confidential information may put me or others at risk of harm or compromise their well being. For example, if I report child or elder abuse or neglect or threaten to harm myself or someone else I understand that necessary actions will be taken and my confidentiality agreement will be limited.

I understand that my coach will not disclose confidential information to third parties unless I give written permission that it be shared.

I understand electronic communications include, but are not limited to, emails, text messages, video-conferencing and voicemail and that the confidentiality of electronic communications can not be guaranteed.

I understand that by communicating with my coach via electronic communications I am implicitly consenting to these communication methods despite their vulnerability and insecurity, and I understand that they may result in the unintentional harmful disclosure of personal information.

By signing below I agree that I have read and understood the confidentiality agreement. I agree to waive all liability toward my coach and I Need Nancy for any injury, loss or damages incurred as they relate to this agreement.

Your Signature

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