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Basic Information

Client Name
Parents Name (if client is a minor)


Understanding Coaching vs. Therapy *
Coaching is NOT Therapy. The work we do will look, feel, and consist of similar concepts to therapy as my approach to coaching mirrors my therapy style. This agreement indicates we are agreeing to engage in coaching sessions via tele-commuication and or in person as decided between provider and client.
Appointments and Cancellations *
Standard appointments times for adults are 60 Minutes. I have a “24 hour cancellation” policy, thus you must let me know at least 24 hours in advance if you need to cancel your session. You are otherwise responsible to pay the full fee for your scheduled appointment time until termination of coaching, whether you attend a session or not. If you let me know at least 24 hours in advance that you will be unable to attend I will attempt to offer you a make-up time, at no additional cost.
Sessions are paid for at the time of our session through our invoice system through paypal unless otherwise stated. Hourly rate may be up to $250.00, unless otherwise discussed.
Video Communication *
FOR COACHING CLIENTS* Method of communication will be decided upon between you and your coach (ie Zoom, FaceTime, etc)
Telephone Calls *
There is no charge for phone calls under 15 minutes. Longer calls will be pro-rated at the client’s hourly rate. Frequent calls may indicate a need for an additional weekly session.
Emergency Calls*
I do not have an emergency phone line. I check messages during the week and will get back to you as soon as possible. If you are having an emergency it is important to seek help immediately by going to a hospital or calling 911.
Confidentiality *
FOR COACHING CLIENTS: Since this is a coaching relationship general confidentiality will be maintained out of respect for the nature of the work we are doing, however there are no legal guidelines to coaching and confidentiality.
Confidentiality and Couples and Family Therapy *
Couples and or family sessions may include both joint and individual sessions. In such circumstances that couple or family hereby agrees to waive their right to confidentiaility so that information shared in individual sessions can be shared in joint sessions at the discretion of the therapist/coach. To maintain an atmosphere of openness and honesty, my policy is that I am unwilling to collude with secrets, wherein one family member shares information with me that they wish to keep from other family members. Any phone calls received from one family member to the coach may be discussed in joint sessions to maintain openness and trust.
Confidentiality and Contribution to Knowledge*
I am committed to the advancement of therapy, and coaching as a science and a profession. I may contribute professional time to teaching, training and supervision improving the standards of coaching. Some of this teaching and writing requires the use of case illustrations, These illustrations are general and do not expose the identity of any person. Unless you notify me to the contrary, it will be assumed that you have no obligation to this work.
Termination of Coaching*
I believe you are the best judge of when to terminate therapy or coaching. I will do my best to provide counsel on the matter, but you must make the ultimate decision about continuing care. I will provide you with referrals if you or I feel progress is inadequate.
Record Keeping*
I will keep brief notes of our sessions that will be kept in a locked file so we can review progress.
General Consent to Coaching*
All information will be kept confidentially through Paypal, and only used once service is rendered.
Your typed name will serve as your signature of acknowledgement that you have read and understand the above statements.

Personal Questions

Have you had previous counseling/Coaching?
If yes, was it successful?
Are you currently taking any medications?
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