Client Disclosure

REBECCA FELLENBAUM CREDENTIALS
Certified Adult Chair® Coach

AS A CLIENT OF REBECCA FELLENBAUM COACHING,

1. I understand that coaching is a comprehensive process that may involve all areas of my life. I acknowledge that deciding how to handle these issues, incorporating coaching into those areas, and implementing my choices are solely my responsibility.

2. 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 including any injuries resulting from recommendations by Rebecca Fellenbaum.

3. I know that I can choose to discontinue coaching at any time, as can Rebecca Fellenbaum, at their discretion. To protect my privacy, six months after I terminate my coaching work with Rebecca Fellenbaum, my coach's notes on me and my assignments may be deleted from their files.

4. I understand that if we engage in any coaching over the Internet, I consent to having sensitive information transmitted via email or video software, acknowledge the risks involved, and waive any rights against Rebecca Fellenbaum for damages arising from any mistakes or errors made in connection with any such transmission.

5. I understand that coaching does not involve the diagnosis or treatment of physical disorders or mental disorders as defined by the American Psychiatric Association. I understand that coaching is not a substitute for counseling, psychotherapy, psychoanalysis, physical or mental health care, or substance abuse treatment and I will not use it in place of any form of diagnosis, treatment, or therapy. I understand coaching may not be appropriate for all people. By signing up for coaching, I acknowledge the possibility that Rebecca Fellenbaum may ask me to discontinue coaching or leave a workshop or other program if they determine it is not appropriate for me. I further acknowledge it is my responsibility to remove myself from coaching if at any point I have concerns about my mental health. 

6. I understand that coaching is not to be used as a substitute for professional advice by legal, medical, financial, business, or other qualified professionals.

FEES/PAYMENT POLICY

Fees for coaching are agreed upon during our initial meeting. When needing to cancel, a 24-hour notice is required or half of the session fee is due. If a “no-show” (meaning the session time has arrived and no cancellation request has been received) the full session fee will be due and charged to the card on file. If no card is on file, an invoice will be sent and payment will be due immediately upon receipt of the invoice. Cash, check, and credit cards are acceptable forms of payment.

CONFIDENTIALITY

Your session is always held in confidence. This means that, as a general rule, information shared in sessions with a coach will be held in confidence. There are two exceptions to this general rule. In the case of an emergency where I believe a client is at risk of hurting him/herself or another person, there may be a breach of confidentiality. 

 EMERGENCY

If at any time you are in crisis and unable to reach me in an emergency, please call 911 or contact the Ohio Suicide and Crisis Lifeline at 988 or go to your local emergency room.

RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT

In consideration of being permitted to participate in Life Coaching offered by Rebecca Fellenbaum, the undersigned participant named below agrees:

• There are social and emotional risks in participating in the above-mentioned activity. I fully understand and acknowledge that there may be risks not known to us or are not reasonably foreseeable to us at this time.

• I accept and assume such risks and responsibilities for the losses and/or damages following such psychological or physical injury, disability, paralysis, or death, however, caused and whether caused in whole or in part by the negligence of the Release(s) named below.

• The UNDERSIGNED further expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the law of the Province or State in which the coach is conducting events and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

• If, despite signing this release, the undersigned participant makes a claim against any of the Releases, the undersigned participant will reimburse the Release(s) for any money which they have paid to the participant, or on his/her behalf, and hold them harmless.

I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY, INCLUDING ANY NEGLIGENCE OF THE COACH NAMED BELOW TO THE GREATEST EXTENT ALLOWED BY LAW. I have saved a copy of this document if desired.

The parties agree that the electronic signature of a party to this Agreement shall be as valid as an original signature of such party and shall be effective to bind such party to this Agreement. The parties agree that any electronically signed document (including this Agreement) shall be deemed (i) to be “written” or “in writing,” (ii) to have been signed and (iii) to constitute a record established and maintained in the ordinary course of business and an original written record when printed from electronic files. Such paper copies or “printouts,” if introduced as evidence in any judicial, arbitral, mediation or administrative proceeding, will be admissible as between the parties to the same extent and under the same conditions as other original business records created and maintained in documentary form. Neither party shall contest the admissibility of true and accurate copies of electronically signed documents on the basis of the best evidence rule or as not satisfying the business records exception to the hearsay rule. For purposes hereof, “electronic signature” means a manually-signed original signature that is then transmitted by electronic means; “transmitted by electronic means” means sent in the form of a facsimile or sent via the internet as a “pdf” (portable document format) or other replicating image attached to an e-mail message; and, “electronically signed document” means a document transmitted by electronic means and containing, or to which there is affixed, an electronic signature.

CONFIDENTIAL: This document contains confidential information and is intended only for the company named. If you are not the named addressee you should not disseminate, distribute or copy this document. Please notify the sender immediately if you have received this document by mistake and delete this document from your system. The integrity and security of this message cannot be guaranteed on the Internet.