Online Coaching Agreement with Buck Black for phone, skype, facetime, or office

Prior to entering into a life coaching relationship, please read the following agreement carefully.  If you have questions, please consult with me, Buck Black, before indicating that you agree with this statement.

 

  1. I will give at least 2 business day’s notice if I cannot keep my appointment.  If I do not give this notice, I will pay a $120 late cancellation fee.
  2. I will pay for my session at least 2 business day's notice in advance.  I understand that if I do not pay, then my appointment will be cancelled.
  3. I understand that life coaching is based around a relationship with a life coach that is designed to facilitate the establishment of long-range goals and short-term objectives and the achievement of those goals.
  4. I understand that the role of the life coach is to assist me with improving the quality of my life
  5. I understand that life coaching is comprehensive in that it deals with almost all areas of my life, including work, finances, health, education, relationships, and spiritual issues.  I acknowledge that deciding on how to handle these issues and implementing my decisions remains my exclusive responsibility.
  6. I understand that life coaching is for people who are already basically successful, well adjusted, and emotionally healthy.
  7. I understand that the confidentiality in the life coaching relationship is limited.  Confidentiality will not apply to certain crimes that have either been committed or are planning to be committed.  Such crimes may need to be reported to legal authorities.  It is also possible that certain topics discussed could be reviewed with other life coaching professionals for training and professional development purposes.
  8. I understand that life coaching does not treat mental disorders as defined specifically in the Diagnostic and Statistical Manual of Psychiatric Disorders. If I have anything in my past indicating that I have an unresolved and serious emotional or physical problem or a mental disorder, I certify that I a not using life coaching as a substitute for assistance from a mental health professional or a medical doctor.
  9. I will not use life coaching as a substitute for counseling, couples therapy, marriage therapy, psychotherapy, psychoanalysis, mental health care, or substance abuse treatment.
  10. If I am currently in therapy or under the care of a mental health professional, I will have consulted with hat person regarding the advisability of my working with a life coach.  Additionally, I will inform my coach of this relationship.
  11. I will not use life coaching in lieu of professional medical advice, legal counsel, accounting assistance, business consultation, or spiritual guidance, and for each of these areas I understand I should consult the appropriate professionals.  I acknowledge that I will not use life coaching as a substitute for such professional guidance.  I further acknowledge that all decisions on dealing with these issues life exclusively with me.
  12. I agree to complete regular evaluations of the life coaching process and notify my coach immediately of any concerns.
  13. I understand that life coaching records will not be submitted to any other professionals, especially when the client is applying for disability, requesting medications from doctors, or participating in lawsuits that require proof of emotional injury or hardship.
  14. If another party, professional or private, is paying for coaching sessions, I agree to have my name, date of session(s), and amount owed disclosed to this party.
  15. I am 18 years of age or older.
  1. If you are considering hurting yourself or someone else, this service is not for you! Please go to an emergency room of a hospital, call 911, or contact the National Suicide Hotline (United States) at 1-800-SUICIDE or 1-800-273-TALK.
  2. Additional phone numbers can be located at suicidehotlines.com
  3. If you are considering hurting someone else, you need to go to a mental health center, emergency room of a hospital, or call 911.
  4. There are no emergency services provided. If you feel there would be a need for emergency services, then please participate in psychotherapy at a mental health center.
  5. I will give at least 2 business day’s notice if I cannot keep my appointment.  If I do not give this notice, I will pay a $115 late cancellation fee.
  6. If I lose contact with life coach Buck Black, I will call him at 765-807-6778 or text him at 765-612-0082 or send him a message through the contact section of www.BuckBlack.com or go to his office/mail a letter at 100 Saw Mill Road, Suite 3102; Lafayette, IN 47905
  7. I have no plans of hurting myself or anyone else
  8. I understand that if I have plans of hurting myself, someone else, or child abuse, I will be reported to the appropriate authorities and will get the help I need.
  9. I certify that I will not operate a motor vehicle or do any other dangerous or multitasking types of behavior during my sessions.  This is a significant safety concern and any distraction may lessen the benefit of the session.

  10. I will pay for services in full at the time of each appointment.  Failure to do so will result in Buck Black Therapy, LLC being unable to provide you with future services.  Please inform Buck Black if you do not wish to have your credit card stored in the secure system for future charges.

  11. If I have an outstanding balance that is not paid within 60 days of invoice, my account will be turned over to a collection agency.  In addition, the balanced owed will be doubled in order to pay the collection agency fees.

  12. Appointment reminders via email are the default.  If I wish to have phone or text reminders or be excluded from reminders, I will let Buck Black know. 

  13. There is a risk that clients will, for a time, have uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories. These feelings or memories may bother a client at work or in school. In addition, some people in the community may mistakenly view anyone in coaching as weak, or perhaps as seriously disturbed or even dangerous. Also, clients may have problems with people important to them. Family secrets may be told. Coaching may disrupt a marital relationship and sometimes may even lead to a divorce. Sometimes, too, a client’s problems may worsen after the beginning of treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that coaching may not work out well for you.