WNY Life Coaching Center Agreement & Disclaimer Form
COACHING DISCLAIMER AND WAIVER
All coaching services delivered by Shawn Marie Cichowski (your “Coach”), are meant to help you identify the areas in your life and in your thinking that may be standing in your way. However, coaching is not professional mental health care or medical care. If you feel psychologically stressed to the point that it is interfering with your ability to function, please have the courage to seek the help you need in the form of a professional counselor.
In that spirit, by purchasing coaching services from your Coach, you confirm that you have read and agree to each statement and that you wish to proceed:
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 New York or any other state. I also understand that for all legal purposes, the services provided by my Coach will be considered to be provided in the State of New York.
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 my Coach will protect my information as confidential unless I state otherwise in writing. If I report child, elder abuse or neglect or threaten to harm myself or someone else, I understand that necessary actions will be taken and my confidentiality agreement limited in this capacity. Furthermore, if my Coach is ordered by a court to provide information or to testify, she will do so to the extent the law requires.
I understand that material provided by Coach and within the website is proprietary, copyrighted and develop specifically for WNY Life Coaching Center Inc. I agree that such proprietary material is solely for my own personal use and that any disclosure to a third party is prohibited.
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 arising 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.
EMAIL________________________________________ Phone: ______________________
Initial Term: __________________ Months From______________
Fee: $_________________________ Per Month or $_________________________Session
Number of Sessions per Month_________________________________________________________________________
Duration____________________________________________(Length of Session Time)
Referred by or how did you find Life Coaching Center_____________________________________
STEPS TO SUCCESS:
Client call/ arrive at the schedule time.
Clients pay coaching fees in advance.
Clients pay long-distance charges if any.
Client will give 24 hour notice prior to your schedule appointment for any cancellations. ‘No-Show” appointments will be considered as a chargeable session.
I understand that life coaching is a comprehensive process that may involve all areas of my life, including work, finances, health, relationships, education, and recreation. I acknowledge that deciding how to handle these issues and implement my choices is exclusively my responsibility.
WNY Life Coaching Center – 5500 Main Street Suite 313- Williamsville, NY 14059