1. I understand that Therapy services can only be provided when I, the client, are physically located in the State of Wisconsin. If at any time you are not physically located in Wisconsin, you will be provided coaching services.

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

3. I understand that coaching does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association.

4. I understand that therapy/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, incorporating therapy/coaching into those areas, and implementing my choices is exclusively my responsibility.

5. 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.

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

7. 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

8. 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.

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

Fees & Payment

10. 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.

11. 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 Therapy & Coaching.

12. 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 names typed below.

Client 1 (Type Name):

Date Signed:

Email: