Name* First Last Date of Birth* Address*City, State, CountryEmail* Phone*Secondary Email in the case of technology failure* Secondary Phone in the case of technology failure*Age*Please enter a value greater than or equal to 18.Martial Status*Occupation*Name of DoctorDoctor PhoneDoctor AddressDate of Last Check Up Date of Last Check UpMedication being taken*Emergency Contact Phone*Relationship to Emergency Contact*Signature*Please sign above using your mouseToday's Date* If under the age of 18, Please enter Guardian's detailsName of Guardian First Last Guardian's AddressGuardian Email Guardian's PhoneGuardian's SignaturePlease sign above using your mouseToday's Date Self Image Studio1. As a client, I understand and agree that I am fully responsible for my physical, mental and emotional well-being during my coaching calls, including my choices and decisions. 2. I understand that “coaching” is a Professional-Client relationship I have with my coach that is designed to facilitate the creation/development of personal goals and to develop and carry out a strategy/plan for achieving those goals. 3. I understand that coaching is a comprehensive process that may involve all areas of my life, including work, finances, health, relationships, education and recreation. I acknowledge that deciding how to handle these issues, incorporate coaching into those areas, and implement my choices is exclusively my responsibility. 4. I understand that coaching does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association. I understand that 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 diagnosis, treatment or therapy. 5. I promise that if I am currently in therapy or otherwise under the care of a mental health professional, that I have consulted with the mental health care provider regarding the advisability of working with a coach and that this person is aware of my decision to proceed with the coaching relationship. 6. I understand that information will be held as confidential unless I state otherwise, in writing, except as required by law. 7. I understand that certain topics may be anonymously and hypothetically shared with other coaching professionals for training OR consultation purposes. 8. I understand that coaching is not to be used as a substitute for professional advice by legal, medical, financial, business, spiritual or other qualified professionals. I will seek independent 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 sole responsibility. All fees are paid in full prior to the start date of individual or group coaching sessions to secure your sessions. Additional appointments can be scheduled as needed. For individual and group coaching packages, all cancellations must be communicated in writing to Gabriella@SelfImageStudio.com at least 48 hour's prior to the start date of the initial coaching session. All fees will be paid in advance. The services to be provided by the coach to the client are face-to-face or zoom/ Skype-coaching, as agreed jointly with the client. Coaching may address specific personal projects, business successes, or general conditions in the client's life or profession. Other coaching services include value clarification, brainstorming, identifying plans of action, examining modes of operating in life, asking clarifying questions, and making empowering requests or suggestions for action. Throughout the working relationship, the coach will engage in direct and personal conversations. The client understands that successful coaching requires a co-active collaborative approach between client and coach. In the coaching relationship, the coach plays the role of a facilitator of change, but it is the client's responsibility to enact or bring about the change. If the client believes the coaching is not working as desired, the client will communicate and take action to return the power to the coaching relationship. The client also agrees to disclose details of past or present psychological or psychiatric treatment. In entering into the coaching relationship, and signing the agreement, you are agreeing that if any mental health difficulties arise during the course of the coaching relationship, you will notify me immediately so that I can discuss with you appropriate steps and if any additional referrals are needed. The client can, at any point in the coaching session, declare his/her preference not to discuss a specific issue, by simply stating that they would rather not discuss this issue. The coach agrees to respect this boundary and will not attempt to forward the conversation further along those lines. All information about the coach / client relationship will remain strictly confidential except in very rare circumstances where decreed by law; ie. where the court might issue a subpoena for the file or information. If you wish for me as your coach to speak to someone outside our interactions, you need to give me written permission via email to do so. Exceptions to confidentiality of course relate to circumstances such as intent to seriously harm yourself or someone else, elder/child abuse etc. Otherwise, all of your information is strictly confidential. It is also important to note that in some situations, it is important to be aware of the use of technology in that for some clients, there is a risk in using certain media such as the internet, cellular phones and cordless phones. If you use these to communicate with me, then I will assume that it is appropriate to continue to do so in my interactions with you. Termination of Coaching under the terms and aforementioned agreements will continue for the duration of the contracted period. Signatures on this agreement indicate full understanding of an agreement with the information outlined above. 9. I understand that Gabriella Phillips is a Certified Coach and Hypnotherapist and is not a licensed physician, psychologist, or medical practitioner of any kind and that coaching should not be considered a replacement for the advice and/ or services of a psychiatrist, psychologist, psychotherapist, or doctor. In recognition that millions of Californians receive a substantial volume of healthcare services from complementary and alternative health care practitioners, California Law allows access by California residents to complementary and alternative healthcare practitioners who are not providing services that require medical training and credentials. The following disclosure is provided in compliance with Section 2053.6 of the California Business and Professions Code. The purpose of this coaching program is for vocational and avocational self-improvement (California Business and Professions Code 2908) and as alternative or complementary treatment to healing arts services licensed by the state of California. A certified coach and hypnotherapist is not a licensed physician or psychologist and coaching/ hypnotherapy services are not licensed by the State of California. Services are non-diagnostic and do not include the practice of medicine, neither should they be considered as a substitute for licensed medical or psychological services or procedures. Hypnosis works with the power of the subconscious mind to change habits and behaviors. The subconscious mind is considered to be the source or root of many of our behaviors, emotions, attitudes, and motivations. Hypnosis is believed to be a powerful tool for accessing the subconscious mind and creating improvements in our lives. Services consist of a program of conditioning, including an undetermined number of private sessions, depending on the client's individual needs. Gabriella Phillips, Certified Coach and Hypnotherapist, will to the best of her ability, endeavor to accomplish the objectives of the clients sessions. While coaching may be an effective technique for a variety of different purposes, the efficacy may vary from individual to individual. No specific outcome, result, or progress can be promised or guaranteed. 10. During coaching/ hypnotherapy sessions, clients remain completely aware of everything that is going on. Many people experience a hyper-awareness where sensations are perceived, enriched, and vivid. The ability to visualize or imagine is enhanced. Deep relaxation is common. Many describe the experience as a meditative state and escape from physical tension and emotional stress, while remaining completely alert. While it is the practice of Coaches/ Hypnotherapists to keep information confidential, information revealed in coaching/ hypnotherapy session(s) is not subject to the psychotherapist-patient privilege. A court may order disclosure of information learned in coaching sessions. I understand the information described above. I also understand and agree that the main purpose of this program is for Vocational or Avocational Self-Improvement and those problems of psychogenic or functional origin are treated by psychological or medical referrals only (Business and Professions Code 2908). Pertinent Details:Before taking part in individual or group coaching session(s) on zoom/skype or in person, please ensure the following: 1. That you will be free from the influence of drugs or alcohol during the course of your session(s). 2. That you provide me with the correct email address of your online location. 3. For online/ skype/ zoom session(s), that the environment around you is safe and will remain distraction free. In addition, please ensure that you provide me with a phone number or other means of communication to contact you with in the case of a technology failure. 4. That you provide me with a third-party emergency contact number. 5. By signing this form, I consent that Gabriella Phillips may release information to a specific individual or agency if it has been determined that a child or elder is at risk of or is currently being abused; If I as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested. I also understand that, at any time, Gabriella Phillips may discuss aspects of my case with other colleagues keeping my full name and identity completely confidential always unless I have given permission otherwise. 6. I understand that any and all forms of harassment, fighting, or disrespect on any level (including any form of discriminatory speech, hate speech, comments or actions against another participant based on their sex, gender, age, ethnicity, race, socio-economic status, disabiliy, or other labels) is not toleraed and will result in immediate and permanent termination from the coaching program without refund. 7. I acknowledge that there is an inherent risk in all forms of electronic communication including unlawful interception by third parties not under our control. Gabriella Phillips does not guarantee the security of any information transmitted via the internet, telephone, video conference, or other electronic media. Participation is done at my own risk. 8. I understand that we uphold a strict cancellation policy and we require a 48 hour cancellation request in writing via email in order for payment to be refunded. Cancellation emails must be sent to Gabriella@SelfImageStudio.com at least 48 hours prior to the confirmed start date of individual or group coaching packages. 9. I understand that I play an active role in the successful outcome of my session(s) and must be motivated to change and follow through with the coaching process. All information presented or recommended by Gabriella Phillips is meant for educational purposes only. If you are unsure about whether or not you should enroll in individual or group coaching session(s), please consult your general practitioner first. I understand that although individual and group coaching has an incredibly high success rate, Gabriella Phillips cannot and does not guarantee results since my own personal success depends on many factors that Gabriella Phillips has no control over, including my willingness and desire to affect the changes inside of myself. I hereby release Gabriella Phillips, Certified Coach and Hypnotherapist, from any liability or claims that could be made against her concerning my mental and/ or physical well-being during the work that has been outlined and agreed upon (now and in the future) by filling out this form. 10. I confirm that I have read and accept the following terms and conditions. SignaturePlease sign above using your mouseToday's Date If under the age of 18, Guardian's Signature:SignaturePlease sign above using your mouseToday's Date This iframe contains the logic required to handle Ajax powered Gravity Forms.
