Please fill out the following information at least 72-hours prior to your first session with Derneeka.
Intuitive Coaching Informed Consent
The client is solely responsible for creating and implementing her own physical, mental and emotional well-being, decisions, choices, actions, and results arising out of or resulting from the coaching relationship and her coaching calls and interactions with the Coach. As such, the Client agrees that the Coach is not and will not be liable or responsible for any actions or inaction, or for any direct or indirect result of any services provided by the Coach. The client understands coaching is not therapy and does not substitute for therapy if needed, and does not prevent, cure, or treat any mental disorder or medical disease.
The client acknowledges that coaching is a comprehensive process that may involve different areas of her life, including work, finances, health, relationships, education, and recreation. The client agrees that deciding how to handle these issues, incorporate coaching principles into those areas, and implementing choices is exclusively the client’s responsibility.
The client acknowledges that coaching does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association and that coaching is not to be used as a substitute for counseling, psychotherapy, psychoanalysis, mental health care, substance abuse treatment, or other professional advice by legal, medical or other qualified professionals and that it is the client’s exclusive responsibility to seek such independent professional guidance as needed. If the client is currently under the care of a mental health professional, it is recommended that the client promptly inform the mental health care provider of the nature and extent of the coaching relationship agreed upon by the client and the coach.
The client understands that in order to enhance the coaching relationship, the client agrees to communicate honestly, be open to feedback and assistance, and create the time and energy to participate fully in the program.
LIMIT OF LIABILITY. YOU EXPRESSLY UNDERSTAND AND AGREE THAT YOU, IN BLOOM, LLC SHALL NOT BE LIABLE TO YOU FOR:
(A) ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL CONSEQUENTIAL OR EXEMPLARY DAMAGES WHICH MAY BE INCURRED BY YOU, HOWEVER CAUSED AND UNDER ANY THEORY OF LIABILITY. THIS SHALL INCLUDE, BUT NOT BE LIMITED TO, ANY PERSONAL INJURY, EMOTIONAL DISTRESS, LOSS OF GOODWILL, OR OTHER INTANGIBLE LOSS;
(B) SOME JURISDICTIONS AND STATES PRECLUDE LIMIT OF LIABILITY CLAUSES. IN THE EVENT DAMAGES ARE ASSESSED, THE LIMIT OF LIABILITY FOR YOU, IN BLOOM, LLC SHALL NOT EXCEED THE TOTAL AMOUNT OF THIS CONTRACT.
(C) IN THE EVENT THAT THE CLIENT DIVULGES INFORMATION THAT I DETERMINE THAT THE CLIENT IS A RISK TO HIM/HERSELF OR OTHERS, I AM LEGALLY RESPONSIBLE TO NOTIFY THE CLIENT’S PARENTS (IF A MINOR) AND OTHER APPROPRIATE PERSONNEL.
THE LIMITATIONS ON YOU, IN BLOOM, LLC ABOVE SHALL APPLY WHETHER OR NOT YOU, IN BLOOM, LLC IS NEGLIGENT OR HAS BEEN ADVISED OF OR SHOULD HAVE BEEN AWARE OF THE POSSIBILITY OF ANY SUCH LOSSES ARISING.
Pillars of a Balanced Life Assessment
Please rate your current levels of life satisfaction on a scale from 0-10 in the following areas. 0 represents completely dissatisfied and 10 represents completely satisfied.