Mindset Coaching Waiver

Client Information Form

Mindset Coaching
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever had mindset coaching in the past?*

YesNoUnsure
I am looking to achieve emotional relief from my session:*

YesNoUnsure
I am looking to achieve spiritual insight from my session:*

YesNoUnsure
Write a brief description of what you are needing coaching with:

Liability & Cancellation Policy

MIndset Coaching
Cancellation/No-Show Policy:

Appointments must be canceled at least 48 hours in advance. There will be a $40 charge for late cancellations or missed appointments.

Liability Waiver:

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 Tennessee. I also understand that for all legal purposes, the services provided by my Coach will be considered to be provided in the State of Arizona 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 including 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, 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 is limited in this capacity.

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 to arise 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.

If in agreement with the terms listed, please sign and date the below:
Date

MonthDayYear
Name

First NameLast Name
Signature

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Client Information Form

Liability & Cancellation Policy