Coaching Agreement

DARLENE A. LANCER
Certified Life Coach
(310)458-0016

Please Print:

NAME:____________________________________Telephone__________________
Address:___________________________________Cell-Phone_________________    City:_____________________________State:_____________Zip Code__________
Email:______________________________________________________________
Age:________Birthplace:____________________Birth Date:___________________
Occupation:__________________________________________________________
Relationship Status:____Dates of Marriage(s): ______________________________
and Divorce(s):_______________________________________________________
Adults living with you:____________________________Relationship:____________
Can I leave personal messages at home?________
Parents/Step-Parents (Names; if deceased, indicate Year of Death or your age then):
____________________________________________________________________
Siblings(Names & Ages):________________________________________________
____________________________________________________________________
Children (Names & Ages):_______________________________________________
___________________________________________________________________

Emergency Contact______________________________Relationship____________
Telephone(s):_________________Email___________________________________
Current Medications (Frequency & Dosage):_________________________________
____________________________________________________________________
Prior Therapy (Dates)__________________________________________________

CONSENT TO COACHING SERVICES

I understand that Darlene Lancer is a Certified Life Coach who provides services, which are alternative and complementary to mental and behavioral health services licensed by my State/Country of _________. She is not a licensed professional counselor in my state. I am engaging her services in accordance with her education, training, and experience as an author and codependency recovery coach with a Masters in Psychology and Certificate of Life Coaching. Distinct from counseling, coaching is an interactive process that improves function and performance through learning, using a variety of styles, skills and techniques. I’m not seeking psychological or counseling services or any other healing art, and I’m aware that coaching is not covered by medical insurance.

Date: ________________________Client:______________________________

FEES AND CONFIDENTIALITY POLICY

Fees are payable prior to appointment on Paypal or via www.Paypal.me/DarleneLancer, and may be adjusted periodically upon 30 days prior notice. Legal interest accrues for Client Consent balances past due. You may pay via Paypal on my website, by adding a 4% transaction fee.  Initial____

I am responsible for payment for any missed appointment, unless it is rescheduled upon at least 48 hours prior notice, subject to coach’s availability. If the appointment is not rescheduled, or if I give less than 48 hours cancellation notice, I will be charged for the cancelled session. Initial____

I acknowledge that coaching is based on a working relationship with my coach and that communication with her is an important part of our work together. If I decide to suspend or discontinue treatment for any reason after the second session, I agree to schedule a final coaching session to talk about it and review and conclude our work together. Initial____

I UNDERSTAND THAT CONFIDENTIALITY MAY BE WAIVED IF MY COACH BECOMES AWARE OF CHILD ABUSE OR ELDER ABUSE, OR IF I PRESENT A DANGER TO MYSELF OR OTHERS.

I AUTHORIZE THE USE OF ELECTRONIC COMMUNICATION AND UNDERSTAND THAT MY PRIVACY AND CONFIDENTIALITY CANNOT BE SECURED WHEN USING ELECTRONIC COMMUNICATIONS, SUCH AS THE TELEPHONE, SKYPE, EMAIL, AND OVER THE INTERNET. I WAIVE MY PRIVACY AND CONFIDENTIALITY RIGHTS WITH RESPECT TO ELECTRONIC COMMUNICATIONS AND TRANSMISSIONS.

Date:____________________________ Client:____________________________

Please print and sign and date this form where indicated. Scan or photo it in full resolution and email it to info@darlenelancer.com.