Name *

First Name

Last Name

Phone *

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Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

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Service Description and Scope *

1) What we offer: Strengths-based, faith-integrated (as desired by client) coaching focused on goals, habits, transitions, resilience, boundaries, and practical strategies. Sessions are not psychotherapy, medical care, or legal/financial advice. 2) Crisis Limitations: I do not provide emergency or crisis services. If you are in danger or experiencing a crisis, call 988, 911, or go to your nearest emergency department.

I understand and agree

Session Details & Policies *

Sessions are 50 minutes and held via video call. Introductory Rate: $50 per session. Future rate changes will be communicated at least 30 days in advance. Cancellation Policy: Cancellations made with 24 hours’ notice or more will receive a credit toward a future session. Credit on your account is good for 12 months and is non‑refundable. Cancellations made with less than 24 hours’ notice are non-refundable and will not receive an account credit. Late Policy: If you arrive late, your session will still end at the originally scheduled time. If you are more than 15 minutes late, the session will be considered a cancellation and the full fee will apply.

I understand and agree

Communication Between Sessions *

Brief check‑ins by email or text are welcome for logistics. Coaching work should be saved for scheduled sessions. Typical response window: within 1–2 business days.

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Confidentiality *

We hold all information you share in confidence except when disclosure is required by law or to prevent serious, foreseeable harm (e.g., risk to self/others, suspected abuse/neglect, court order). To serve you best, we may discuss your case with another trusted professional, but we will limit identifying information as much as possible. You may submit a release of information form if you would like us to collaborate with another provider.

I understand and agree

Coaching vs. Therapy — Important Disclaimer *

Coaching supports personal/professional growth and goal attainment. It is not for diagnosis or treatment of mental disorders and does not replace therapy, psychiatry, or medical care. We may offer referrals if therapy or another service appears more appropriate.

I understand and agree

Tele‑Coaching Consent *

You consent to meet via secure video call. You agree to be in a private, distraction‑free location and not to record sessions without mutual written consent. Technology issues may occasionally cause interruption; we’ll reconnect or reschedule as needed.

I understand and agree

Records, Data, & E‑Signature *

We may maintain minimal records of session dates, fees, goals, and progress notes. You authorize the use of reputable third‑party platforms (e.g., scheduling, payment processing) to manage appointments and payments. You consent to sign electronically and to receive copies via email.

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Term, Satisfaction, & Ending Services *

Coaching is voluntary. Either party may pause or end coaching at any time. *Reminder* Credit on your account is good for 12 months and is non‑refundable. Feedback is always welcome.

I understand and agree

Client Acknowledgment *

I have read, understood, and agree to the terms above.

Today's Date *

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