[ 1 ]  Important Medical Disclaimer

This website, the book and articles I've written, and all stop-smoking coaching (hereafter, "Information") is intended to educate you about how to stop smoking and quit tobacco with methods derived from the field of naturopathy and allied sciences, and to encourage you to make healthy choices in wellness. Although I’ll propose a course of naturopathic intervention for you, and provide you information to review and educate yourself, the decision to proceed or modify your plan will always rest with you and your health care provider! My role as a coach is that of an educator. It is up to you¾your body, mind and spirit¾to heal from tobacco; it is not up to me or anyone else.

All Information is provided with the understanding that I am not liable for any misconception, misuse or use of the Information nor am I, as a coach, engaged in the practice of psychology, counseling, medicine, offering medical advice, or curing any disorders or diseases. As a coach, I am simply providing information available in the public domain and scientific literature. I leave the final choice of what information to use up to you and your health care provider. My coaching is limited to providing information, sharing experiences, and empowering you to make your own choices for health.

Considerable effort has been made to make this Information as complete and as accurate as possible. Again, the purpose of this Information is to educate you to make your own choices; the Information is not intended to treat or cure any disease or disorder. I shall have neither liability nor responsibility to any person or entity with respect to any loss, damage or injury caused or alleged to be caused directly or indirectly by the Information provided, or any use thereof. The Information presented herein, and stop-smoking coaching, is in no way intended as a substitute for medical and psychological counseling nor to be construed as the practice of psychology, psychiatry or medicine, or the offering of psychological, psychiatric or medical advice. 

If you do not have one already, you are encouraged to seek the partnership of a qualified health care practitioner of your choice, such as a naturopathic or an allopathic physician, before coaching or using Information I provide. When I coach you for tobacco cessation I will collaborate with your physician or other health care provider, at no additional charge to you, in order to insure the appropriate medical supervision from your own health care provider.

If you have any special conditions requiring attention (medical, psychiatric or psychological), you are advised to consult with your health care practitioner regularly regarding possible modifications of the Information contained in my book and via coaching, and collaborate with your health care provider. [Consent Version 1.0]

 *  By typing (signing) "yes" [lower case, no quotes] I, the client, acknowledge having read—completely and in its entirety—the above Disclaimer and Informed Consent, that I have had all my questions answered to my satisfaction prior to signing, and understand and agree to the terms and conditions above, and hereby give my informed consent for coaching, without reservation.

[ 2 ]  Coaching Agreement

Session Day/Time

Please re-enter the day and time of our sessions that we agreed upon below (e.g., Tuesdays, 2:00pm, EST):

Any changes must be made via telephone and confirmed either by fax, e-mail, or telephone at least 24 hours in advance.

Session Options & Fees

* Your monthly coaching fee is per month. To encourage your commitment, the 12 week program (3 months of coaching, 3 - 4 sessions per month) needs to be paid in advance. (You will be also be billed a one time in-take charge of $199 at the onset of your smoking cessation coaching program for history taking; this includes all assessments.) Each program (or subsequent coaching) is payable in advance using this website's Payment Center. Personal checks are accepted but held for three weeks for clearance before any coaching can commence. Once you submit this consent and agreement paperwork, you'll be sent to the Payment Center; please enter the naturopathic stop-smoking program amount of there.

Calls/Internet Procedures

Coach will call you at the pre-arranged number on the day and time scheduled. Your fees include all telephone-related charges within the United States. The time will begin when the call is placed; interruptions and 'holds' will be counted as part of the allotted time. We can use e-mail for brief communications and questions. I reply to my mail either first thing in the morning, or in the evening after my last client.

Termination

This Agreement is for three months (9 - 12 sessions). You'll have the option to extend it on a month-to-month basis afterwards, with the mutual agreement of both of us. Should you or I determine that insufficient progress or cooperation exists after the initial three months, either of us may cancel this Agreement without recourse. Cancellations must be in writing and sent by fax, e-mail or mail.

Confidentiality

Coach recognizes that certain information of a confidential manner may be relayed by you, the client, during either regular or “Coach-on-Call” sessions. I, your coach will not, at any time directly or indirectly, use this information for my benefit nor disclose said information to anyone else without your specific written approval. This excludes disclosure of illegal, unethical or other activities for which I may be mandated by law to report. If you are in doubt about a disclosure, please ask beforehand.

Nature of Relationship

I am a founding member of Coachville, the world's largest educational institution for life coach training, and have been coaching for three years. I have 20 years of experience in the addictions field, specifically tobacco cessation also¾ applied behavioral analysis and a B.A., M.A. and Ph.D. in psychology (Wichita State, Rutgers); Psychologist and Director of Clinical Psychology Services at the Center For Addictive Diseases (Blackwood, NJ); training in wellness and naturopathic modalities, including medical hypnotherapy and mind-body medicine (Atwood Institute, 1993, and Philadelphia College of Clinical Hypnosis, 1984); 2800 hour diplomate in homeobotanical therapy from the Australasian College of Health Sciences (New Zealand and Portland, Oregon); training in goal setting and achievement technologies.

    I want to reiterate that the coaching relationship is in no way to be considered or construed as medical treatment, psychological counseling or any type of therapy; further, it is not a substitute for medical care. You are also aware that although coaching results vary, I provide a guarantee. You agree that you are entering into coaching with the understanding that you, ultimately, are responsible for the results you achieve. You also agree to hold me free of all liability and responsibility for any actions or results for adverse situations created as a direct or indirect result of specific referral or advice given by me and you agree to the terms presented in the Medical Disclaimer and Informed Consent agreement herein. [Coaching Agreement Version 1.0]

By completing the form below, client acknowledges having read—completely and in its entirety—the above Coaching Agreement as well as Disclaimer and Informed Consent, have had all questions answered to client's satisfaction and understands and agrees to the terms and conditions above, and client  hereby gives informed consent for coaching, without reservation.

* Your name, mailing address and telephone number:

              Your name, address and telephone number goes here

* E-mail  

  Special requests, or modifications negotiated:

Your health care provider:

            Dr. Street Town, State, Zip code Country Telephone Fax

Do NOT collaborate. If you check the box to the left, it means that you DO NOT want me to collaborate with your health care provider, and that you feel comfortable assuming responsibility for making your own decisions regarding quitting tobacco, and that you will consult your health care practitioner if/when you feel the need. You can fill in "None" in the box above. Otherwise, if left un-checked, I'll consult with your health care provider, at no charge to you, and please fill in the information above.

By filling in the information above and submitting, I hereby agree to the conditions contained in both documents, Version 1.0. I also agree that this transaction is governed by the Electronic Signatures in Global and National Commerce Act (E-Sign Act), 15 U.S.C. §7000, et seq

[ All that's left is for you to fill out a brief tobacco use history - and you'll be sent there next after submitting this document ]