Vibrant You! Group Coaching Agreement This agreement is being entered into by and between Certified Health Coach, Stacey Rosenberg and the client/participant who is named below. "*" indicates required fields Participants Name* First Last Please share your preferred pronouns.Email* Phone*Date of Birth* MM slash DD slash YYYY With my signature below I hereby acknowledge and agree:*General Coaching Agreements. Please select the box to the left of each statement. 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 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 in advance of the session. Select AllCOMMUNICATION* 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: 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. 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. GROUP COACHING AGREEMENT*Group Coaching is a professional relationship in which Coach works together with a number of clients in a group setting, facilitating discussions meant to clarify areas that the participants would like to improve, and to help clients work toward achieving their desired outcomes in those areas. I agree to attend all scheduled sessions to the best of my ability. I understand there will not be any refunds for missed sessions. I understand and agree that all information shared in group coaching is confidential except in circumstances governed by law, such as abuse and danger to self or others. All parties agree to take all reasonable measures to ensure confidentiality with anything shared in the group or other communication over the phone and/or Internet. This includes anything that is said by individuals in the group and recordings of the sessions. Our sessions together will be on Zoom. I understand that I am required to keep my camera on and remain present during the session. (Emergencies excluded) Sessions will be recorded in case of an inevitable absence. Participants will have a particular time window to watch the video and agree to not share the recordings with anyone outside the group. I agree to complete assignments on time and to the best of my ability. I agree to participate fully within the group. As a client/group participant, I understand and agree that I am fully responsible for my physical, mental and emotional well-being, including my choices and decisions. I am aware that I can choose to discontinue coaching at any time. Consent* With my name below, I agree to all of the statements above.Client Signature*Date* MM slash DD slash YYYY CAPTCHA Δ