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COACHING - CLIENT AGREEMENT
(PLEASE PRINT OUT, READ THE INFO, SIGN, AND RETURN BY E-MAIL, MAIL, OR FAX)
**If you have questions or concerns you would like to address before signing, feel free to contact me by calling me @
1-800-880-1605 Ext. 7. Or email me at Renee@LactCorp.com, or e-mail me using the form on the "Contact" page. I will return your message asap.
The fax # to return documents : 800-894-1392.
otherwise known as the Client, agree to receive Life, Health & Wellness Coaching
Services, and/or Parent Education for either *myself (circle if yourself),
or my minor child (then known as the client, put child’s name here) _______________________________________,
or the person for whom I have Guardianship/Power of Health Care Attorney (then
known as the client, put that person’s name here), ___________________________________,
by Renee D. Murphy (Hughes), M.A.
I understand and agree that these services are not clinical or
diagnostic in nature, and that Ms. Murphy (Hughes) is not representing herself
as a Licensed Professional Counselor able to practice outside the state of
I understand and agree that any of the venues I choose to receive my coaching
services in, will be priced according to The Schedule of Venues and Fees posted
on the Our Journey Through Life Website, unless otherwise agreed on in writing.
Ms. Murphy (Hughes) will assist me with my overall goals or concerns that are
within her area of expertise by using such methods as: effective goal-setting
techniques, providing necessary education
(including reading or other exercise’s between appointments), teaching
effective communication skills for both personal and professional use, help
refine decision-making skills, assist the client to discover their strengths and challenges
and balancing them with skills, talents, & interests. These personal, yet guided
self- assessments/discoveries are meant for the client to become clearer on their
life and career goals, wellness (self-care), and to offer support and guidance,
and make referrals as needed and able.
I understand and agree that any personal information, outside of basic data
info which may be accessed by the IT and/or Office Personnel, will be kept
confidential per the notice of Confidentiality and Privacy which I was provided
and is posted on the website aforementioned. Otherwise, any information will be
shared only with my Consent for Release of Information other than for the
exceptions to confidentiality as outlined in The Confidentiality & Privacy
Statement as required by law of Ms. Murphy (Hughes), as a mandated reporter.
Usual open hours for Face-to-Face services are listed on the website sited
below. I understand that Ms. Murphy (Hughes) will try to make other accommodations
for scheduling when I cannot fit an appointment into her open hours. However, I
also understand that she is under no obligation to do so, and that this is
considered a courtesy service. I understand and accept responsibility for
providing 24 hrs notice in advance of any missed appointment via ANY venue
(phone, internet, F/F). Otherwise, I may be charged for that missed appointment
to be paid prior to the next session, if it was not unavoidable, at the discretion of the
Coach. The Coach also holds the right to terminate services if there is a
pattern of cancellations without notice. The Coach retains the right to
terminate services if 3 (three) appointments in a row are missed. The Coach
will make every attempt possible to also give 24 hrs notice to cancel, and will
ask for a phone # for distance clients as well as face-to-face clients in order to be
able to call if there is any valid reason why she may need to cancel, and/or
if there are internet problems that are causing the need to cancel
If a set number of sessions were agreed on at a certain price, and the client
decides to cancel any particular # of sessions, they may do so with notice of a
minimum of 2 sessions. That will provide both the Client and the Coach the time
to wrap up any work in progress, make any referrals, or
to make changes to the coaching goal plan if the client wants to go in another
direction. During that 2 week session notice period, it would also allow time
to open up discussion between the Coach and Client to facilitate
that. The Coach always encourages feedback from the client so any changes
can be made that would make the coaching experience as successful as possible.
Any further sessions that the Client has agreed to, but still might want
to cancel after the 2 session notice, they will not be responsible for, and any
monies paid will be returned within 30 -45 days.
By signing below, I also am attesting that I have read and I am aware of the
background and expertise of the Coach and therefore the scope of her services.
I also understand and agree to her policies regarding scheduling, cancellation
of appointments, rate of payment, and payment methods listed on her website –
I further understand that payment information is collected up-front
before a session is started and is processed through Paypal. By signing below,
I agree that it is my responsibility to pay for all professional services rendered by
this Coach. As stated above, if I pre-paid for sessions and decide to terminate early,
I agree to provide at least a 2 session notice to the Coach in writing. If the Coach
is forced to seek legal advice and collection against me for my debt that I am
responsible for, then I am also responsible for those costs incurred to the
Coach and/or her payment service provider.
SIGNATURE OF CLIENT OR
**DATE OF BIRTH OF MINOR IF SIGNING
AS PARENT/RESPONSIBLE ADULT:___________________
This service agreement is valid for one (1) year from
the date of the signature unless client puts in a different date or rescinds
this in writing and it is received and recorded. Anything released prior
to that cannot be rescinded. Date of expiration of
Copyright @ Our Journey Through Life. All Rights Reserved