Resolution Today
Rachael Haskell, PhD, LCSW
Mailing Address: 6177 Sun Blvd. #404, St. Petersburg, FL 33715
Phone (727) 698-2543; Fax (727) 865-6507
www.ResolutionToday.com
Life Coaching Agreement
Client Name: ______Date of Birth: ______
Email: ______Phone: ______
Address: ______Allergies: ______
Emergency Contact: ______Phone: ______
1. I, ______, am voluntarily seeking coaching for
(responsible party)
______from RACHAEL HASKELL
(client ) (coach)
2. It is the responsibility of Rachael Haskell, PhD, LCSW, to bill for services provided. It is my responsibility to pay for services at the time the service is rendered.
3. I understand that if I have a scheduled appointment and I need to cancel it, I will do so at least 24 hours in advance or more if possible. If I do not provide 24 hours notice, I may be charged for the appointment.
4. I understand that my coach will recommend specific types of assignments to reach my goals. She will explore the advantages and risks of each with me. My coaching may involve hypnosis, bilateral exercises, cognitive behavioral tasks, or other kinds of activities for resolution of stress and personal growth. It is good for me to ask questions if I need assistance.
5. I understand that my life coach will make every attempt to keep what we talk about in sessions confidential and that my coach will not disclose information to anyone without asking me first, except for the following as required by law: physical or sexual abuse of a minor child or a vulnerable adult, clear intent to harm oneself or someone else, or court order from a judge.
6. I also understand that my coaching, in keeping with generally accepted standards of practice, may seek confidential supervision regarding my coaching plan. The purpose of such consultation is to assure quality care. Every effort is made to protect my identity.
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Resolution Today
Rachael Haskell, PhD, LCSW
Mailing Address: 6177 Sun Blvd. #404, St. Petersburg, FL 33715
Phone (727) 698-2543; Fax (727) 865-6507
www.ResolutionToday.com
Life Coaching Agreement
Client Name: ______
7. I understand that when my coach is not available for consultation, I can reach an on-call counselor for crisis support at 2-1-1 Tampa Bay Cares Inc. (immediate confidential consultation with an experienced professional needed to avert harm to self or others), as well as for emotional support and resources, 24 hours/7 days per week. If a situation is urgent within office hours of 1p to 8p, and I understand that my coach may be available to speak directly. I will leave a message at the above phone number and can expect a call within 12 hours. I also understand that if I need medical help, physical safety or immediate help with an emergency situation, I will call 9-1-1 first.
8. Brief notes about our work together may be maintained with my permission for 1 year after completion on a password protected completion. Should I require a copy, I will submit a written request to release records to my coach, and this decision will be at her discretion.
X
Signature of Client Date
If Signature is typed in, you are consenting to using your
typed name as your Electronic Signature
Signature of Witness Date
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