DARLENE A. LANCER
Certified Life Coach
Address:___________________________________Cell-Phone_________________ City:_____________________________State:_____________Zip Code__________
Relationship Status:____Dates of Marriage(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):_______________________________________________
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 the state and country of where I reside. 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.
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. Sessions purchased as part of a package must be weekly. No reimbursement or substitution will be made for any weekly appointment that is missed or skipped. Initial____
Interest of 1 1/2% per month accrues for past due balances. A $12 fee will be charged for any check returned for insufficient funds. I agree that I’m responsible for all costs, fees, and expenses for collection of past due balances, including legal fees. 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 suspend or end 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.
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