Healing Hearts Coaching Services, LLC
Grief Coaching Client Agreement Form
Prior to entering into a professional companioning and/or coaching relationship, please read the following agreement carefully and indicate your understanding by signing and dating it below. If you have any questions or concerns, please communicate with your companion and/or coach before signing it.
1. I understand that grief coaching is a relationship with a certified griefcompanion/coach that is designed to offer support, education, compassionate listening and coaching to assist the client to better understand and move through the process of normal grief. Certification as a grief companion/coach does not in any way qualify my coach to practice higher levels of grief therapies. Certification as a grief coach does help ensure that my coach can identify symptoms of more complicated grief and refer clients to a qualified and licensed therapist.
2. I understand that self-care coaching is a relationship with my coach that is designed to create and implement an individualized action plan of self-care in order to support me to fulfill my intentions and goals for a greater sense of health, well-being and higher quality of life.
3. I understand coaching is a holistic or comprehensive process that may deal with many areas of my life including health, education, work, stress mastery, spirituality , relationships, play, self-esteem, life purpose, as well as other pertinent concerns and feelings.
4. I understand that I am responsible for all of my decisions, actions and feelings during a companioning and/or coaching session, as well as outside of the session. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Healing Hearts Coaching Services, LLC and Noelle Y. Ellis from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).
5. I understand that companioning and/or coaching are for individuals who are already well adjusted and emotionally healthy.
6. I understand that companioning and/or coaching do not deal with the diagnosis or treatment of emotional problems, nor do they constitute medical consultation or treatment.
7. I understand that companioning and/or coaching are not a substitute for mental health care, psychotherapy or substance abuse treatment.
8. If I am currently in psychotherapy or under the care of a mental health professional, I have consulted with this person as to the appropriateness of working with a grief companion and/or coach at the same time as therapy. I will also inform all parties of my decision to seek both types of services simultaneously.
9. I understand that all information will be confidential, unless I make a written request for it to be otherwise. Exceptions will be made if there is an apparent threat of harm to myself or to others. It is also possible that certain topics of our sessions may be discussed in a confidential manner with other companions and/or coaches for educational and training purposes.
10. I agree to regular evaluations of the companioning and/or coaching sessions and will notify my companion and/or coach immediately of any concerns.
11. I understand that my companion and/or coach acknowledges and commits to the Code of Ethics as outlined by the Energy Medicine Professional Association (EMPA).
12. The time and day of the appointment is scheduled at the mutual convenience of the companion and/or coach and the client. The day and time will be scheduled at the end of each appointment.
13. If I need to cancel or change a session, I must do so at least 24 hours before the session; otherwise, I will be charged the full fee. My companion and/or coach will make a reasonable effort to reschedule in a timely manner a session that has been cancelled.
14. All payments for sessions will be made through PayPal, cash or local check. Once a payment is made, there are no refunds for unused sessions.
15. Either party may terminate the companioning and/or coaching relationship for any reason by providing the other party with a notice by e-mail, fax or regular mail.
16. I commit to coming to each session with an open mind and heart and will focus, to the best of my ability, on my journey towards healing and wholeness.
17. I understand that the intuitive domain is an inexact science, as is the energy body. Results may vary and cannot be guaranteed.
Please Print Name_______________________________________________ Date___________________
City_______________________________ State_______________________ Zip_____________
Copy Sent to Client on ____________________________________________
Noelle Young Ellis, B.A.
Certified Grief Intuitive Coach & Reiki-One Practitioner
P.O. Box 325
Bass Harbor, ME04653