PERSONAL COACHING AGREEMENT
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- Baldric Booker
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1 PERSONAL COACHING AGREEMENT Full Name:_ Nickname (if any): Mailing Address: Work Phone: Cell Phone: Home Phone: Fax: Address:_ Website(s):_ Date of Birth: Marital Status: Significant Other's Name: Names & Ages of Children: Other Important Name Relationship People in Your Business or Life: What You Want to Gain from coaching: - 1 -
2 This agreement, between Jennie Owens (herein named as COACH) and the above named CLIENT, will begin on (DATE) and will continue for a minimum of months. The fee for our initial 90-minute meeting is $65. For those choosing to participate in parenting coaching, the in-office fee is $45/hour and the in-home observation and coaching session will be $65 an hour for two to three hours. The fee for each month of coaching is $90, payable in advance on a monthly basis. The monthly fee covers two hours of scheduled coaching sessions each month, plus unlimited brief check-ins as needed. The fee will be refundable on a prorated basis in the event of illness or other serious emergency. If client wants to meet on a weekly basis, monthly fee will be $180, which will include weekly sessions, plus unlimited brief check-ins as needed. Upon completion of the initial three months, our agreement will convert to a month-tomonth basis. The CLIENT and COACH agree to provide one another with two weeks notice in the event it is desired to cancel further service. The service provided to the CLIENT by the COACH is parenting and/or self-care coaching, as designed jointly with the CLIENT. Coaching, which is not counseling or therapy, may address overall goals, specific projects, or general conditions in the CLIENT's life or profession. Coaching services may include setting priorities, establishing goals, identifying resources, brainstorming, creating action plans, asking clarifying questions, and providing models, examples, and in-the-moment skills training. The COACH promises that all information provided by the CLIENT will be kept strictly confidential, as permissible by law. Throughout our coaching relationship, the COACH will engage in direct and personal conversations with the CLIENT, which will include asking explicit questions and making requests. The purpose of these interactions is to remind the CLIENT of his/her own intentions, and coach him/her to realize them. In order for our coaching relationship to achieve the maximum result, the COACH asks that the CLIENT agree to the following: 1. I agree to be on time to all appointments. If I will be late, I will notify the COACH in advance. If I will miss an appointment, I will notify the COACH at least 24 hours in advance. Appointments missed without 24 hours notice will only be rescheduled at the COACH s discretion. 2. I understand that the purpose of my sessions with my coach is to assist me in goals related to my own personal development. I take personal responsibility for the results of my coaching experience. I understand that if the coaching is not working as I desire, I will communicate and take action to return the power to the relationship to myself. 3. I agree to be honest and participate fully. I understand that my commitment is essential to my success. I recognize that our sessions are a safe place to look at what I really want, and what it will take to make it happen. 3. I will make a commitment to the action plans I create, and do what I have agreed to do. 4. I understand that my coach is not a trained psychotherapist and will NOT be acting
3 in the role of a counselor, hypnotherapist or psychotherapist during our coaching sessions. I further understand that coaching does not take the place of psychotherapy or any other profession advice for psychological, legal, financial, medical or any other matters normally handled by other professionals. 5. I understand that my coach will honor my confidentiality unless required by law to disclose information about me. 6. I give my coach permission to be honest, direct, supportive, and to challenge me. 7. I understand and agree that I am fully responsible for my well being, including my choices and decisions. I understand that I am always free to reject any advice, suggestions or requests made by my coach at any time. The CLIENT's signature on this agreement indicates compliance with the above requests, and understanding of the services to be provided. CLIENT Date COACH Date:
4 Have you recently experienced any of the following? Please circle all that apply: Difficulty falling asleep Waking up in the middle of the night Fatigue Waking up tired Depression Poor memory Trouble relaxing or resting Feeling anxious or nervous Getting sick more than usual Muscle weakness Stomach/GI issues Headaches Decreased tolerance to cold Brain fog Difficulty concentrating Increased irritation or agitation Muscle twitches Increased salt cravings Increased sugar cravings Unexplained weight loss Unexplained weight gain Women Only: Increased PMS symptoms Periods worsened Please describe your current self-care choices. Check all that apply: Emotional Self-Care: I am very aware of my feelings and am able to express them in healthy ways I take some quiet time for myself during the day I take adequate time to meet my own needs I do something fun at least once a week I have hobbies and interests beyond my traumas Physical Self-Care: I get adequate sleep I exercise on a regular basis I eat a balanced, healthy diet I limit my intake of sugar and junk foods I drink plenty of water I go to the doctor, dentist, etc. when I need to I avoid harmful habits like smoking, drugs, etc. Relational Self-Care: I have adequate support system for my current stress level I have friends I can call when I m down, friends who really listen and understand me I make time for friendships I am able to ask for help when I need it I am investing in and nurturing my relationship with my spouse I am able to say no to requests without feeling guilty
5 List any recent stressors/trauma: List your current stressors: Financial: Family: Work: Other:
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