1. As a client, I understand and agree that I am fully responsible for my physical, mental and emotional well-being during my coaching sessions, including my choices and decisions. I am aware that I can choose to discontinue coaching at any time.

2. I understand that “coaching” is a Professional-Client relationship I have with my coach that is designed to facilitate the creation/development of personal, professional or business goals and to develop and carry out a strategy/plan for achieving those goals.

3. I understand that coaching is a comprehensive process that may involve all areas of my life, including work, finances, health, relationships, education and recreation. I acknowledge that deciding how to handle these issues, incorporate coaching into those areas, and implement my choices is exclusively my responsibility.

4. I understand that coaching does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association. I understand that coaching is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment and I will not use it in place of any form of diagnosis, treatment or therapy. I understand that Jay Blevins/Blevins Coaching and Consulting is neither licensed as nor acting as therapist or mental health professional.

I understand that information will be held as confidential unless I state otherwise, in writing, except as required by law and/or in the following circumstances -

• There is reason to believe that I intend to harm another person.

• There is reason to believe I intend to harm myself.

• I provide information regarding reportable child abuse of any kind.

5. I understand that certain topics may be anonymously and hypothetically shared with other coaching professionals for training OR consultation purposes.

6. I understand that coaching is not to be used as a substitute for professional advice by legal, medical,
   financial, business, spiritual or other qualified professionals. I will seek independent professional guidance for legal, medical, financial, business, spiritual or other matters. I understand that all decisions in these areas are exclusively mine and I acknowledge that my decisions and my actions regarding them are my sole responsibility.

How Sessions Are Conducted

7. I understand that sessions may be conducted in-person or via video conferencing. Reminders of upcoming sessions will be sent by email. A link for the videoconference will be included, if appropriate. Phone sessions may be used with prior agreement.

8. I understand that the initial intake session is 90 minutes. Other session are typically 60 minutes; however, longer sessions are also available.

Fees & Payment

9. I understand that the initial intake session is $165 and ongoing sessions are $125 per hour. I also understand that rates may change from time to time. You will be provided 90 day notice of any rate increases.

10. I understand that payment for sessions may be made at the time of booking, anytime prior to the session, or immediately after the session unless other arrangements are made. Payment may be cash, check, or charge. Checks should be made out to Blevins Coaching & Consulting.

11. I understand that scheduled sessions must be cancelled 24 hours in advance or the session fee will still be charged.

How many clients will be signing this form? 123 (If there are more than 3 Clients, please contact me for instructions.)

I/We accept these terms as indicated by my/our signature(s). (Sign using mouse or finger on touchscreen)

Client 1 (Type Name):

Client 1 Signature:

Date Signed:

Email: