Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Pricing Packages *

Single Session Rate = $75

Fees *

I, the client, understand and accept that… 1. Single Session Rate @ $75 x One (1) forty-five (45) minute session (voice/video) = $75 2. There is a service fee of $3 for each therapy/coaching session. 3. Payment must be made in advance of all scheduled therapy/coaching sessions. 4. Payment must be made online using a credit or debit card.

I confirm that I have read, understood and agree with the above.

Cancelation and Rescheduling *

I, the client, understand and accept that… 1. If I need to reschedule/cancel a therapy/coaching session, I must provide at least 24-hours’ notice. 2. If I fail to provide at least 24-hours’ notice, I will be charged the full session fee.

I confirm that I have read, understood and agree with the above.

Refund Policy *

I, the client, understand and accept that… 1. There are no refunds once services have been rendered.

I confirm that I have read, understood and agree with the above.

Terms *

As a therapy/coaching client, I understand and agree that I am completely responsible for my well-being during my time in therapy/coaching. This includes my choices and decisions. No guarantees have been made to me as to the expected outcome of my therapy/coaching. I am aware that I can choose to discontinue therapy/coaching at any time. ** For Coaching Clients ONLY - I recognize that coaching is a process, and it is not psychotherapy. A professional referral is given if it appears psychotherapy is needed.

I confirm that I have read, understood and agree with these terms.

Today's Date *

MM

DD

YYYY