Take Action Mindfully

Life Coaching

Coaching Agreement & Informed Consent

This is a formal contract between the Coach Ashley Focht M.Ed. and the
Client ____________________________________________________.

Services:
1. This agreement is for coaching services. Life Coaching is not currently regulated in the state
of Ohio and it is the sole discretion of the client to determine the effectiveness of services.
2. Life Coaching is not a form of psychotherapy or counseling services. Though Coaching
services can help clients identify and reach goals while changing behaviors that are not
working for a client, it will not address issues such as depression, anxiety or serious mental
health concerns. For support with these, you must see a Licensed Mental Health Professional.
By signing this form, you are stating that you read and agreed that you understand the
difference between services and will seek out Mental Health Services if necessary.
3. Life Coaching is a collaborative process that is present and future focused and committed to
growth.
4. As the Client, you set the goals for the session, your goals, and your success. You will be
responsible and held accountable for your own progress. The Coach will be direct,
straightforward, challenging, and use techniques to support you in moving forward.
Scheduling:
1. Please contact the Coach through Websites, email, or telephone
2. Once contact is made and an appointment date, time, and type (phone/webcam/face-to-face) is
agreed upon client must make a payment through Paypal
3. If the Client does not make payment through Paypal- the appointment is not withstanding and
coach will not meet with client

Cancellations:
1. Clients must give 24-hour notice of canceled appointments by email or telephone.
2. If a Client fails to do so before the 24 hr period there will be no refund and the appointment
will be charged.

Fees:
Telephone Coaching Web Cam Coach Face To Face Coaching
30.00 - 30 Min 45.00 - 30 Min 60.00 - 30 Min
45.00 - 45 Min 60.00 - 45 Min 75.00 - 45 Min
60.00 - 60 Min 75.00 - 60 Min 100.00 - 60 Min

Termination:
1. Either party may terminate the Coaching relationship for any reason.
2. Termination must be provided through written transmission of email.

Availability:
1. The Coach will be available to you at your scheduled appointment time.
2. Email contact between sessions is welcome at an up-front additional service rate that will be
discussed, agreed upon, and contracted during a coaching session.
Confidentiality
Your information and goals will be kept confidential unless you have given written
permission for me to release your information.

There are limitations to confidentiality:

1. If I am required to release your information by a court order I must do so.
2. I am legally obligated by Federal and State laws to breach confidentiality in order to protect
others from harm in the following cases:
If you have indicated that a child, elderly or disabled person is being abused.
If you are at imminent risk to harming yourself.
If you have made threats of imminent violence against another person.

Groups:
1. Some sessions are held in a group setting and in this case, each client agrees to maintain
confidentiality of all information communicated by all parties involved.
2. All Limitations to confidentiality apply to group coaching as well.

Confidentiality and Transmission of Electronic Information

1. Please be aware that it is not 100% possible to protect confidentiality of Client information
through electronic transmission (email, information stored on computers connected to the
internet, mobile telephones, and other devices connected to internet connections).
2. The client is solely responsible to use encryption and other forms of security protection in
order to keep their identity safe and confidential.
3. By signing this agreement, you the Client ______________________________________ are
waiving any action legal or otherwise against the coach for any interception of your
information resulting from the use of above-mentioned equipment.
4. By Signing this agreement you are stating that you have read, understand and agree to these
terms related to confidentiality and transmission of electronic information.

Mutual Nondisclosure:
1. The Coach will be utilizing many techniques with client during the Coaching process. This
agreement states that the client will not disclose or communicate any information regarding
the Coachs information, practices, materials, or methods to any third parties.
2. Clients are bound to this agreement during and after termination of services.

Dispute Resolutions:
Client agrees that any controversy or claim arising out of or relating to this agreement, or
breach of this agreement, shall be settled by arbitration by an accredited individual or
organization with an arbitrator whom we shall mutually agree upon. The Arbitration may
occur by telephone, web cam, or face to face.

Your signature below states that you have read the information in this Agreement and Informed
Consent: as well as indicates you agree to the Terms of this Agreement and will abide by these terms
during and after our professional Coaching relationship.

Client:__________________________________________ Date:________________

Coach:__________________________________________ Date:________________

In the event of a Crisis or Medical Emergency, please call 911 or the appropriate emergency services
to request assistance. Your coach cannot handle Emergency Matters.