New Clients: Please print out, fill in the appropriate blanks, sign & date and fax to 518.483.4823 or mail to Edward Blomgren, Ph.D., Postal Box 123, Owls Head, NY 12969
Coaching Agreement
Session Day/Time
Please enter the day and time of our sessions that we agreed upon below (e.g., Tuesdays, 2:00pm, PST):
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. Please enter the naturopathic stop-smoking program amount of here.
Calls/Internet Procedures
Coach will call you at the prearranged 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), and may be extended on a month-to-month basis following the initial program of three months, with the mutual agreement of both parties. 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 or unethical 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 wellness and
naturopathic modalities, including medical hypnotherapy and mind-body medicine
(Atwood Institute and Philadelphia College of Clinical Hypnosis); 2500 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 psychological counseling, or any type of therapy; further, it is not a substitute for medical care. You are also aware that coaching results vary, and that 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 data:
Your data:
Name
Address
Telephone & Fax
cc: Client will be provided a signed copy
Coach records
FAX to 518.483.4823, OR mail to
Edward R. Blomgren, Ph.D.
Postal Box 123
Owls Head, NY 12969