A hard copy of this agreement will be provided to you.
PLEASE READ BEFORE ANSWERING QUESTIONS: (estimated time to complete all pages is approximately 5-10 minutes) Refresh or reload the page to clear the form and start over.
Please provide the following information and answer "ALL" the questions below.
Please note:"ALL" questions are "REQUIRED" and very relevant/necessary for by the coach for an appropriate goal setting plan of action.
These questions are NOT required. Please answer the following question if you would like to apply for reduced rates:
Please note that verification may be required and requested. If you do not want to apply scroll down and click the next button.
Welcome to your journey of coaching! I am honored to be your ally and coach. I believe that each person deserves a powerful life that they love! I will be your advocate as you discover and design a life that works, has freedom, opportunity and an open space to create possibilities! We are a team, and I’m committed that together we accomplish every desire and goal that you bring forth.
My Clients are Amazing People
All my clients are empowered people whom it is my genuine good fortune to serve. I will enjoy working with you.
The Roles of Coach and Client
The role of a coach and client is as peers. I am a trained professional coach and a licensed therapist. However, my role as you coach is not to provide diagnosis or treatment. Our coaching relationship is about YOUR goals and desires always. I will listen, reflect, ask questions, give perspectives, and options. I will encourage, promote and support you to find and foster your integrity. However, I believe that YOU are the expert in your life, and I am an ally and tool to use as a resource to help you accomplish your goals. As my client, I ask you to show up fully prepared and present for each session, pay attention to what has heart and meaning, tell the truth without blame or judgment and be open to outcome rather than attached to outcome. I will do the same.
I Expect You’re Best
If you are hiring me I imagine that you are ready to make meaningful transformation inside and out.
I’m Here for YOU
Our relationship is a top priority for me. I ask that you use me as the resource and friend that I am.
Please share with me your wins, challenges, anything you like, as well as your coaching experience. I want to know what works as well as what does not. I am committed to serving you.
If between live sessions you need to ask questions, share breakthroughs or breakdowns, bounce some ideas around, you can send a chat message, e-mail me at [email protected]@talk.org or call (816) 873-1968 to leave a voicemail message. I respond to messages daily (Monday-Friday) and even sometimes on weekends. If and when I'm available.
I Don’t Miss Much
If I hear something in your voice or notice something is amiss, I’m likely to ask you about it. Often, it is the small moments that bring about BIG shifts.
I ask clients to challenge themselves, improve the work done in the sessions by taking some actions, resolving relationships or work on situations that feel incomplete. You are free to accept or decline. Negotiate for what is right for you. Please come prepared to create something you want for yourself.
Ways You Can Get More From Your Coaching Experience
*Make our coaching sessions a priority.
*Come to every session with a specific agenda.
*Do the work between sessions.
*Utilize what you learn; complete what you agree to do!
*Be open minded.
*Try new approaches.
*Get to know who you are right now, and be open to transform into who you would like to be.
*Tell the truth to yourself, to everyone.
* Be willing to transform your beliefs if they do NOT serve you anymore!
I understand that the acceptable payments are American Express, Discover, Health Savings Account, MasterCard, PayPal, and Visa.
I understand that the first payment is taken at time of agreement.
I understand that fees are payable based upon term of payment plan (weekly, monthly, quarterly, semi-annually, or annually) . So if you start weekly on a Monday, fees are due each Monday. If you start monthly on the 5th then fees are due each month on the 5th.
I understand that all payments are due prior to service rendered. However, if we discuss another arrangement openly, I can be flexible.
I understand that all billing and administrative data is secured.
I understand that if I qualify, a sliding scale fee can be applied.
* Please include fees in your monthly budget.
Sliding Scale Criteria
1. Income (from employment, disability, or otherwise) below $30,000 per year.
2. Unemployed for at least 6 months or have never been employed.
3. Currently on some form of public assistance or social security/disability.
4. A single mother or father.
5. A full time student.
If qualified, the sliding scale fee will be determined prior to or during your initial assessment and will be based upon the criteria met above.
Should your financial situation change, your fee will be reassessed and it is your responsibility to notify us of any changes.
* I will be available for all scheduled live sessions. Please make sure your available and online or at the phone number given at the scheduled live session time.
* If you forget or miss a session without communicating ahead of time it will count as your live session.
Schedule changes/ Vacations/ Business Trips
Please give our live sessions high priority and arrange your schedule to honor our agreed upon time. If you must reschedule, I ask you to give me 24 hours notice. In any case, let me know as soon as you are able. I will not reschedule no call/no shows. If you have a vacation or business trips that will conflict with our sessions, please notify me of these as soon as you have an itinerary and we will discuss when to reschedule. I will do the same with you when I plan trips.
Please make sure to fully read and understand all policies and procedures. I invite you to ask questions. I will be as flexible as I can as long as it has us both being empowered, and a commitment/agreement are in place.
I understand that live phone consultations are scheduled.
VERIFY THE CLIENT’S IDENTITY/VALIDITY ELECTRONICALLY ONLINE TERMS OF SERVICE
Clients provide their full name. Clients are asked to verify their identity more formally by showing a government issued photo ID on the video screen and or emailed or faxed copy.
My email address is: [email protected]
Clients are welcome to email me with scheduling questions or other concerns. Because the privacy of email cannot be guaranteed, I encourage clients to consider other methods for communicating sensitive information (encrypted secure email options are available). I do return phone calls as promptly as possible. Because I may not see an email notification promptly, please do not use email to notify me of an urgent matters. You are welcome to leave an messages at 816-873-1968.
I frequently come across information that may be pertinent to a particular client's progress. Clients are welcome to provide me an email address with permission to contact them, and I will send links to useful information as I come across it. This information is simply as an educational adjunct to the coaching process.
Because I want to share resources and helpful information with as many people as possible, I do
maintain a page on Facebook. This is a public page, without any of the privacy settings that are available to individuals. I use this page to share resources, and answer questions if they are appropriate for a public forum. Clients may browse this page without "liking" it. However, if you choose to "like" the page, please make sure that you are fully aware of the level of sharing and privacy that you have enabled on Facebook. The settings for the page include a publicly visible list of those who have "liked" it. I do not "friend" clients on Facebook because I believe that puts us at risk of forming a dual-role relationship, which is prohibited by my ethical guidelines.
While I use the Facebook page primarily to share information, I also maintain both a Twitter account and a Linked In profile. These tools provide me outlets to share information, and a way for me to network with professional colleagues. My Twitter account is a publicly shared account, so anything posted on my Twitter feed is public information. I do not answer questions via Twitter because of its public status.
Please use email or telephone for questions.
I do not follow clients on Twitter, and I don't encourage clients to follow me, although if you choose to do so, be aware that the account is public, and your name would be listed in my "Followers" list. I do not connect with clients through my Linked-In profile, because that is also a public forum.
My primary concern is that my clients' privacy be as protected as possible. Any connection through social media presents a possible compromise of that privacy, so I do not encourage clients to do so.
Please contact me directly with any questions or concerns. My office is equipped with voicemail, which I frequently check throughout the day and evening for updated messages. I will make every reasonable attempt to respond to all messages within the same day, but it may be up to 24 business hours before I return your call.
An electronic record is kept for each client for whom remote services are provided. Records includes an
intake form, client identification information, contact information, history, goal setting plan, informed consent, and information about fees and billing. A goal setting plan based upon an assessment of the client's needs is developed and documented. The plan includes a description of what services are to be provided and the goals for services. Services are accurately documented as remote services and include dates, duration and type of service(s) provided.
Documentation complies with applicable jurisdictional and federal laws and regulations.
Requests for access to such records require written authorization from the patient with a clear indication of what types of data and which information is to be released.
The purpose of the collection, use and disclosure of your personal information is for the provision of professional coaching, including supervision for the purposes of improving provision of such coaching services. Only your coach has complete access to your records while they are in the coach's custody. Administrative staff cannot access my coaching records, but may have access to general account information.
This Agreement will remain in effect for one year from the date of your last coaching session. Tina C. Christian, LPC, NCC reserves the right to change the terms of this Agreement at any time, as long as you are allowed the ability to agree to the new terms.
If any part of this Agreement is deemed by a American court of appropriate jurisdiction to be illegal, invalid, or unenforceable, that part of the Agreement shall be limited or eliminated to the minimum extent necessary so that this Agreement shall otherwise remain in full force and effect and enforceable. This agreement constitutes the entire, final, complete and exclusive agreement between the parties and supersedes all previous agreements, proposals or representations, oral or written, relating to this agreement. You are not permitted to modify or amend this agreement.
I understand that I am still responsible for paying my coach for missed or cancellations of a scheduled appointment with less than a 24 hours notice unless it is due to illness or an emergency. The Coach will make every effort to reschedule any properly scheduled sessions.
I understand that if I fail to cancel a scheduled appointment, the coach cannot use this time for another client and I will be billed for the entire cost of my missed appointment.
I understand that if I cancel all future services, and if payment has been received, I will be refund for all unused services at a prorated amount (minus any discounts) with 45 days from my request. If after that time I have not received a refund, I am to email to [email protected]
I understand that:
Submission of this information indicates that you have READ, TRUTHFULLY AND ACCURATELY COMPLETED, AND AGREE to ALL the terms of these forms. You will be contacted by the coach soon as the information has been reviewed to schedule your appointment.
Please note that a secured and encrypted copy of the forms you're submitting will be provided to you by the coach, through a secured online file sharing option during your first appointment. Please feel free to contact the coach at anytime by phone at (816) 873-1968.
Thank you for taking the time to submit your online coaching consent forms, and I look forward to being your ally in your journey to empowerment!
TINA C. CHRISTIAN, LPC, NCC,TF-CBT Trained
256 -BIT ENCRYPTION DATA TRANSMISSION
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