Health Coaching Agreement This agreement is being entered into by and between Certified Health Coach, Stacey Rosenberg and client (named below)* First Last Please share your preferred pronouns. Email* Phone*With my signature below I hereby acknowledge and agree:*Please select the box for each statement. Select All I affirm that I am at least 18 years of age or older. I understand that participation is voluntary and I may withdraw at any time by notifying my coach via phone or email. I am aware that the Discovery Session will be 60 minutes and follow-up sessions will be 45 minutes. I am aware that health coaching will take place on Zoom at a day and time that is mutually agreed upon. Calls begin and end at set time. If you are late, you will forfeit the missed time. I understand that I am expected to make all calls on time and will contact my coach at least 24 hours in advance if an unavoidable conflict arises. I am aware that I will receive health coaching from a Functional Medicine Certified Health Coach and understand that Health Coaches are not medical doctors and cannot diagnose disease, disorders, or conditions. I am aware that coaches are not healthcare providers and coaching does not replace seeing a licensed medical physician, dietician, nutritionist, or naturopath. I understand that this coaching relationship is in no way to be considered or construed as psychological counseling or any type of therapy or medical intervention. I understand that coaching is its own unique process that draws upon strategies for goal attainment and my health coach will guide me towards reaching my health and wellness goals. I am aware that coaching results cannot be guaranteed. I affirm that I am fully responsible for the choices and decisions in my life and am responsible for my own results. I agree that it is my responsibility to tell my coach what works and what does not work, and to be honest about how I would like to be coached. I understand that the coach may release me from coaching for any reason, including but not limited to inappropriate conduct of my doing. I agree to hold the coach free of all liability and responsibility for any actions or results for adverse situations created as a direct or indirect result or specific referral or advice given by the coach. I agree to complete all questionnaires given to me by the Health Coach 48-hours PRIOR to the next appointment time. COMMUNICATION* All additional questions and communication outside of appointments will be done through email (exceptions considered by the Health Coach based on the client's individual communication styles). The Health Coach reserves the right for response to take up to 48-hours. As part of the health coaching Services, I may be asked to provide information concerning my physical habits, medical history, moods, energy levels, likes and dislikes, lifestyle and diet. This information is collected to enable the health coach to better assist me on my journey to optimal health. The health coach will hold this information in confidence and will not release or disclose this information to any other person, without my prior consent, except as required by applicable law. SCOPE OF PRACTICE*I understand that my Health Coach’s scope of practice is limited to lifestyle management. This includes the following: Select All 1. Developing and achieving self-determined goals related to health and wellness. 2. Supporting in mobilizing internal strengths and developing self-management strategies for making sustainable, healthy lifestyle, behavior changes. 3. Focusing on achieving health goals and behavioral change based on self established goals. 4. Providing accountability toward healthy lifestyle change. SESSIONS + PACKAGES The 15-minute discovery session is complimentary. If you would like to take the journey to coach with me, the next step is to purchase a Live Vibrantly Package. This package includes a 60-minute Foundation Session and six, 45 minute follow-up sessions. Sessions are scheduled every two weeks at the same day and time. Package payment is required before booking the Foundation Session. Split payments are available on an as needed basis. Once you have completed the initial package you can continue with follow-up sessions at a package price, or purchase them individually as you need support. Live Vibrantly Package: Regular Price: $750 Introductory Offer: $550 (Paid in full before the foundation session.) Split Payment Option: $450 to start. $300 before we meet for session four. A credit card is required and you will be charged automatically.Split payments are not available for introductory pricing Six Follow-Up Sessions: Regular Price:$600Introductory offer pricing available for one year from original coaching start date. $450 IIndividual Session: $120 (only available to those who have completed a Live Vibrantly Package.)CONFIDENTIALITY* As a matter of ethics, my coach affirms that she will maintain strict confidentiality about all information shared by me. The only exception is if my coach has reasonable cause to believe there are threats of serious harm to myself or others. My coach is then obligated to report the situation to the proper agent. All communication will be HIPAA compliant and held to a standard of a medical care professional. Signatures on this agreement demonstrate the intent to fulfill the intentions and requests above and reflect a complete understanding of the services provided. Consent* I agree to all of the statements above.Client Signature* Date* MM slash DD slash YYYY CAPTCHA Δ
