Client consent form for coaching

Please complete all of the form fields.

Live (phone or video) 60-min sessions are $75 US/hour
Virtual support (as part of the hybrid session) is $55 US/per week (or per hour if additional time is required)
Additional Consulting is $75 US/hour

I have voluntarily requested Health Coaching services for myself or my child. I understand that the cost for each session will be paid via paypal invoice or e-transfer.

I understand that it is my health coach's responsibility to explain health coaching procedures that may be used, including their advantages and any possible disadvantages.  I agree to be responsible for asking questions or discussing any concerns I may have about coaching.  I expect that any and all information about me (or my child) will be held strictly confidential by my coach.  This includes all discussions with my coach and any written materials.

However, I understand that there are some circumstances whereby the information cannot be kept confidential.  These are:
a.  If my coach determines that I am a danger to myself or others (or the child is in danger to themselves or others)
b.  If the names of a child or elderly person that is being abused is disclosed
c.  If the records are subpoenaed from the courts for any reason.   

Furthermore, no information will be released to any other individual or agency, without my written consent, unless as specifically required by law or if there exists a danger of harm to myself or someone else.  My health coach will make every effort to safeguard my personal information.  

I understand there may be situations whereby health coaching is not the appropriate support service for a particular client.  In such instances, a client may need to be referred to another office or agency. Any such decision will be made at the discretion of my health.  I understand that I may withdraw my consent for services and my agreement with the above procedures at any time.  Finally, I understand that Jeannette Folan is a registered integrative health coach with the Health Coach Alliance & Canadian Association of Integrative Nutrition, and does not currently carry Commercial Liability insurance. I have read and understood this form.  

By Submitting this electronic form, you are agreeing to these terms.

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