• Real Talk with Simone’s Waiver and Release of Liability Form

  • By signing and reading this waiver form, you acknowledge that Real Talk with Simone is a phone, online, one on one talk therapy / life coaching / counseling service with out the state license.

     

    Real Talk with Simone is a business that provides a safe environment where someone can share something and that topic of discussion will be held confidential, unless there is something stated that has the potential for harm toward the individual themselves, another human being or the community.

     

    Real Talk with Simone is a listening service that will provide advice or feedback, within the counseling services.  If topics of discussion go beyond the scope and realm of just venting and discussing things about life, then Real Talk with Simone will gladly recommend other recommended psychologists that can help on an advanced cognitive level.

  • By agreeing to Real Talk with Simone's Waiver and Release of Liability Form, please type your first and last name as well as fill out the date in which you agreed to the form.

  •  - -Pick a Date

  •  REAL TALK WITH SIMONE’S STATEMENT FOR HAVING THE RIGHT TO NOT DO BUSINESS

  • 1.       A person who expresses hatred toward a person of race, religion, sexual orientation, ethnic background, age, etc.

    2.       If at any reason during the period of the session, a person gives off sexual innuendos, advances, or displays any kind of sexual harassment during the session.

    3.       A person who gives off any kind of physical threats during the session.  The individual who gives off threats will be reported to officials.

     

     

    BY SIGNING THIS FORM AND SENDING IT BACK TO REAL TALK WITH SIMONE, MEANS THAT YOU HAVE READ AND UNDERSTOOD THE TERMS AND CONDITIONS STATED IN REAL TALK WITH SIMONE’S RIGHT NOT TO DO BUSINESS.  ANY ADDRESS TO VIOLATE ANY OF THESE REASONS TO NOT DO BUSINESS, MEANS THAT YOU FORFEIT THE RIGHT TO HAVE COUNSELING SERVICES PROVIDED TO YOU EVER AGAIN FROM REAL TALK WITH SIMONE.

  • By agreeing to Real Talk with Simone's Statement of the Right to not do business with someone, please fill out your first and last name as well as the date in which you agreed to the form.

  • NO SHOW / LATE POLICY:

  • YOU AGREE THAT IF YOU ARE 15 MINUTES LATE OR DON'T SHOW, WITH NO NOTICE AT LEAST AN 1 HOUR IN ADVANCE THEN A FEE OF $10 WILL BE ADDED TO THE NEXT SESSION 

  •  - -Pick a Date
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