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COACHING CLIENT AGREEMENT & INFORMED CONSENT FORM

I (Thomas Miller) am very excited to work with you and I’m ready to sprint with you towards your goals! This agreement is intended to provide important information regarding your choice to engage Thomas Miller & Thomas Miller Coaching, LLC. Thomas Miller is a Licensed Independent Clinical Social Worker in MA, & has practiced psychotherapy services since 2002. However, please be advised that Thomas Miller will not be practicing under his psychotherapy license and will not provide psychotherapy services through Thomas Miller Coaching, LLC.

You are choosing to engage Thomas Miller Coaching, LLC for the sole purpose of receiving coaching services. By accepting this agreement, you (the client), agree that you understand the distinct difference between coaching and psychotherapy. You (the client) agree to the following statements.

I (the client) understand that:

• Coaching neither treats mental disorders nor conducts mental health evaluations.
• If Thomas Miller/Thomas Miller Coaching, LLC detects or suggests that I suffer from a mental health/substance abuse disorder and determines that I need to be evaluated for mental health/substance abuse concerns then he will recommend that I find a licensed mental health professional.
• If this recommendation is made I understand that Thomas Miller/Thomas Miller Coaching, LLC will not provide me with any psychotherapy services.
• Coaching is not psychotherapy or counseling and that professional referrals will be given if needed.
• If I am currently in therapy or counseling, or otherwise under the care of a mental health professional I certify that this mental health professional is aware of my decision to enter into a coaching relationship.
• 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 psychotherapy.
• My coaching sessions are not medically necessary and my coaching sessions cannot be reimbursed via my health insurance.
• I am also fully aware that Thomas Miller/Thomas Miller Coaching, LLC does not provide crisis services.
• If I am experiencing a medical/mental health emergency during the course of my coaching work with Thomas Miller/Thomas Miller Coaching, LLC I agree to either go to the nearest emergency room or call 911 to request emergency assistance.

The Nature of the Coach Relationship

I (the client) understand that:

• The purpose of my relationship with Thomas Miller/Thomas Miller Coaching, LLC is to create, develop, and facilitate my personal, family, professional, career, or business goals.
• The purpose of coaching is to develop and to implement a strategy, plan, and/or program that is designed to achieve those goals.
• Coaching is not to be used in lieu of professional advice. I will seek professional guidance for legal, medical, financial, business, spiritual 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 responsibility.
• I can choose to discontinue coaching at any time. Although coaching is a process that may involve several areas of my life, including career / work, finances, health, and personal and professional relationships, deciding how to manage these issues and implement my choices is solely my responsibility.
• I can read more about coaching online or on the web site of the International Coach Federation (ICF) at www.coachfederation.org.

Records & Confidentiality

I (the client) understand that information transmitted by me in this coaching relationship will be kept strictly confidential unless I give explicit, specific, written permission to release it to specifically designated persons. I (the client) understand that the only exception to this confidentiality will occur if the release of personal information is required by law.

When Disclosure is Required or May be Required by Law:

I (the client) understand that some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client’s family members communicate to Thomas Miller/Thomas Miller Coaching LLC that the client presents a danger to self or others. I (the client) understand that disclosure may also be required pursuant to a legal proceedings.

Hold Harmless

As a result of signing this agreement I (the client) agree to hold Thomas Miller/Thomas Miller Coaching LLC harmless for the state of my personal, professional, and/or financial life. I (the client) assume full responsibility for the results that I achieve during and outside of coaching. I (the client) agree to indemnify and hold Thomas Miller/Thomas Miller Coaching LLC harmless from any legal claims, actions, or judgments.

Intellectual Properties

I (the client) understand that during my work with Thomas Miller/Thomas Miller Coaching LLC I will be exposed to intellectual properties that are unique to Thomas Miller/Thomas Miller Coaching LLC such as techniques, methods, ideologies, or materials that cannot be shared without his expressed written permission. I (the client) understand that Thomas Miller/Thomas Miller Coaching LLC will also protect his client’s intellectual property or personal/business information.

Attendance Expectations

It is a great opportunity to work with you (the client) and to help you achieve your goals and experience success. I (Thomas Miller) take this opportunity very seriously and I expect my clients to do the same. Therefore, 48 hours of notice is required prior to the time of the appointment for all cancellations. Please email: thomasm@thomasmillercoaching.com to cancel any appts. Clients will be charged the full hourly amount if they late cancel or no-show for their appointment.

Fees

Coaching sessions are billed at an hourly rate of $350. If you request Thomas Miller Coaching, LLC to perform additional services such as emailing and or phone calls, and or additional services outside your scheduled coaching sessions those services will be billed at the hourly rate stated above. Thomas Miller Coaching, LLC does offer one time only sessions, though this is not recommended to achieve full results.

Telecoaching

I (the client) consent to engage in telecoaching i.e. video conference and or telephone based coaching sessions with Thomas Miller Coaching, LLC. This will be the primary mode for my coaching sessions. I (the client) understand that despite reasonable measures on the part of Thomas Miller/Thomas Miller Coaching, LLC there is a possibility that our coaching sessions could be disrupted or distorted by technical failures. In addition, I (the client) understand that telecoaching services and care may not yield the same results nor be as complete as face-to-face services.

I (the client) agree that printing my name in the signature line below represents my full signature & acceptance of this agreement. I (the client) agree that I have read the agreement carefully and I (the client) understand its contents. If I (the client) require further information I (the client) am fully aware that I may ask Thomas Miller / TMC further questions.