Success Slow Coaching - Confidential Client Intake Form
Please complete this form ONLY if you are committed to the monthly coaching package
with Tania Davies and are ready to start!
FEES & PAYMENT: You are agreeing to enter into a monthly business coaching package with Tania Davies. Monthly Payment is due in full prior to the 1st day of the following month ("Coaching Month"). You will be sent an invoice for payment by EFT (preferred) or credit card. Credit card fees apply. Invoices will be sent on the last Monday of each month for the following month and you are able to end this agreement at anytime by emailing notice to contact@taniadavies.com. Monthly pre-paid packages are not refundable once the Coaching Month has begun.
CANCELLATION POLICY: You are entitled to 4 x 90 min online coaching sessions with Tania Davies per calendar month at a rate of $1500 plus gst per month. Your time slot is reserved exclusively for you. Please arrive promptly to obtain your full session. A 24-hour cancellation notice is required, except in an emergency. If you must cancel or reschedule due to an emergency, please notify us as soon as possible. In the event that you do not arrive for your session and proper prior notice has not been made, you will forfeit this session. If notice is given it can be rescheduled at the availability of the Practitioner within the same month or carried over to the next month, provided the following Coaching Month is pre-paid in full. Thank you for your consideration
CONFIDENTIALITY: All therapist’s communications, records and contracts with clients and professional and support staff will be held in strict confidence. Clinical Progress Notes may be released, in accordance with the law, only when: (1) The client signs a written release of information indicating informed consent to such release; (2) The client expresses serious intent to harm himself/herself or someone else; (3) There is evidence or reasonable suspicion of abuse of a minor, an elderly person (sixty-five years or older), or a dependent adult; or (4) A court order is received directing disclosure of information. Hypno-Psychotherapy notes are the property of the therapist and will be retained in strict confidence without release to any party. It is our policy to assert (a) a privileged communication in the event of #4. Although we cannot guarantee it, we will endeavour to apprise clients of all mandated disclosure.
SAFETY: Sessions may be video recorded for client and practitioner safety. These recordings are kept confidential and are securely filed.
MEDICAL HYPNOSIS: Hypnosis is effective in relieving some medical conditions (i.e., pain management, migraines, IBS, etc.) but will require a signed release from your doctor or appropriate health care professional to avoid masking symptoms before proper diagnosis and/or medical treatment has been obtained. Of course, non-medical issues (i.e., smoking, weight loss, confidence, etc.) will not need a form. I understand Hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counselling and I also understand that the Hypnotherapist does not treat, prescribe for or diagnose any condition.
RELEASE STATEMENT: I give my full consent to receiving sessions by Tania Davies and Mindful Impact™ for the purposes outlined in this intake form and for future purposes that I may request. I understand that the success of my sessions depends greatly on my own ability and desire to affect change in myself. I understand that the results of my session(s) depend greatly upon my own serious participation and that Tania Davies and Mindful Impact™ cannot offer any guarantee of the success of my treatment. I am aware, however, that Tania Davies and Mindful Impact™ will do everything in their power to ensure my success and I agreed to participate in each session to the best of my ability. I hereby release Tania Davies and Mindful Impact™ from any liability. I also understand that I have other choices from which to seek assistance regarding my specific concerns, and I have chosen NLP/Coaching/Hypnosis/Psychotherapy at this time. I have been advised that I am free to terminate any or all sessions at any time. I have accurately provided background information as requested by Mindful Impact™.
COOLING OFF: You can cancel this Agreement within 7 days from the Start Date by giving us written notice. When you sign this Agreement you are entering into a legally binding contract with us. By signing here, I agree to be bound by the provisions of this Agreement. If I choose to cancel, I understand that there will be a administrative cancellation fee of $100.