Life Coaching Intake Packet

The conversations that we have within our coaching sessions are confidential and will be protected as such. Information will be shared outside of our sessions only with your written consent or in the event that a Court Judge demands it. However, the following are instances where I would be obligated by law to break our confidentiality agreement without your permission:

• If it is assessed during your participation in coaching sessions that abuse or neglect of children or elders is occurring.
• If in my presence you threaten to kill or harm another individual, and I am convinced that you may act on this threat, or that you may lose control of your actions.
• If at any time during the course of our sessions I determine that you are a danger to yourself, or you threaten to kill yourself, and I am convinced that you may act on this threat, I will inform you of that opinion and make every effort to keep you from endangering your life. In some cases this may include notifying the law enforcement or family members.

The purpose of this agreement is to make sure we share the same understanding about how we will work together in our coaching relationship.

Clients must agree to the following:

• I recommend a commitment to the coaching process and open and honest communication between coach and client, including feedback from the client on a regular basis. You are your own best expert and I require your input and questions. This is a collaborative effort, the more you put into it the more you will get out of it.
• Full payment must be made at time of services rendered. The cost of sessions is: $120 for 50-60 minute sessions via Telehealth and $175 for 50-60 minute sessions in-person. Credit card payments are accepted. The credit card is charged by our Administrative Team at the time of the session. For any session not cancelled within 24 hours or for a missed session, a $55 fee will automatically be charged to the credit card on file.
• Client must respect session time limits.
• Coach and client will come to sessions free from distractions and focused on the task at hand.
• Coach and client agree to arrive at sessions at the scheduled time. A reschedule or cancellation must be made at least 24 hours before an appointment to avoid the missed session fee. No-shows are unacceptable for both coach and client. If a client misses two appointments without notice, the coaching relationship will be terminated. In the event of an emergency, exceptions may be made on a case-by-case basis.
• Frequent communication is encouraged. I want the client to know that he/she/they can reach out at any time for support or to keep me apprised of your progress towards your goals. Short emails and calls of 10 minutes or less will not be charged. We will agree on the appropriate boundaries of communication outside of session when we complete the intake appointment.

I have read and agree to the working agreements above and will honor them during our coaching relationship.

Life Coaching should be conducted when emotional or psychological issues are healed or are in the process of healing. Coaching is not therapy. If you feel that you are not able to function psychologically, please seek out help in the form of a professional counselor. Please read the following and sign below if you fully understand and agree to each statement:

• I understand that the Life Coaching services offered by MySpectrum Counseling & Coaching are NOT offered as a substitute for mental health care. I also understand that my coach is not acting as a psychologist or Therapist, and does not purport to offer mental health care.
• I understand that my coach will maintain the confidentiality of our communications only to the extent defined by the laws of the states in which each of us resides and have been given a copy of my coach’s confidentiality agreement.
• I understand and agree that I am fully responsible for my well-being during my coaching sessions, including my choices and decisions.
• 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 hereby release, waive, acquit and forever discharge MySpectrum Counseling & Coaching, their 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 actions, omissions, or commissions taken by myself or by MySpectrum Counseling & Coaching as a result of the advice given by MySpectrum Counseling & Coaching or otherwise resulting from the coaching relationship contemplated hereunder. I further declare and represent that no promise, inducement or agreement not herein expressed has been made to me to enter into this release. The release made pursuant to this paragraph shall bind my heirs, executors, personal representatives, successors, assigns, and agents. I have read the statements above and I understand and agree with the points contained therein: