Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

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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. *

Yes

No

I understand that coaching is a Professional-Client relationship 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. *

Yes

No

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. *

Yes

No

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. If I am currently receiving psychiatric care, I will consult with my caregiver to ensure working with a coach is in my best interest at this time. *

Yes

No

I understand that information will be held as confidential unless I state otherwise, in writing, except as required by law. I understand that if I reveal information that involves physically hurting myself or others, the coach must report such information and/or refer to mental health professionals accordingly. *

Yes

No

I understand that certain topics may be anonymously and hypothetically shared with other coaching professionals or clients for training, educational OR consultation purposes and that Sean Cohen will take great care to change any identifiable details to protect my privacy. *

Yes

No

I understand that coaching is not to be used as a substitute for professional advice by legal, medical, financial or other qualified professionals. I will seek independent professional guidance for legal, medical, financial, 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. *

Yes

No

I understand that if I decide to commit to a coaching package with Sean Cohen (single sessions, 3-month programs, or 6 month programs), that payment must be completed before sessions are scheduled. *

Yes

No

I understand that if I need to reschedule or cancel a session, that I must clearly communicate (in writing via email) this need at least 48 hours before the scheduled session time. I understand that failure to do so forfeits said coaching session. *

Yes

No

I understand that because professional coaching is not considered medical consultation or treatment, health insurance is not applicable for payment. *

Yes

No