Initial____ Print Client Name_______________________________
Print Parent/Guardian’s Name, if applicable_______________________________
Liability Release Form Please read and agree to the following disclaimer and release of liability. Life coaching is not a counseling service. Concetta Kirschner does not provide clinical counseling or psychotherapy. Life coaching is not meant to be a substitute for clinical counseling, treatment for suicidal ideation, depression or severe psychiatric problems. The information provided by Concetta Kirschner does not constitute legal or professional advice neither is it intended to be. It is to be used for educational and entertainment purposes only. As a client, it is important to understand the difference between life coaching and clinical counseling or psychotherapy. While there are similarities between life coaching and clinical counseling/psychotherapy, the major differences are in the goals, focus and level of professional responsibility. Clinical counseling/psychotherapy is a health care/medical service and is usually reimbursable through health insurance policies. Life coaching is not a health care or medical service. Therefore, coaching services are not reimbursable through health insurance policies. It is also important to understand that coaching is a professional relationship. While it may often feel like a close personal relationship, it is not one that can extend beyond professional boundaries either during or after our work together. Considerable experience shows that when boundaries blur, the benefits gained from the coaching relationship are endangered. RELEASE OF LIABILITY The client or his/her parent or guardian agrees that using any of these life coaching services are entirely at his/her own risk. Life coaching services are provided "as is," without warranty of any kind, either expressed or implied, including without limitation any warranty for information services, coaching, uninterrupted access, or products and services provided through or in connection with the service. This service is requested at the client’s or his/her parent’s/guardian’s own choice and with inherent singular responsibility. The client or his/her parent/guardian agrees that the use of all, or part, of the service is entirely at the client’s own risk. Any actions or lack of actions, taken by the client of such advice is done so solely by choice and responsibility of the client and is neither the responsibility nor liability of Concetta Kirschner. The client or his/her/her parent/guardian understands that life coaching is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and the client will not use it in place of any form of therapy. The client or parent/guardian recognizes that coaching requires emotional, physical, and mental efforts, exertion, and behavioral experimentation, on the client’s part, which may cause physical, mental or emotional injury. The client or parent/guardian fully acknowledges and takes full responsibility for all the risks involved. The client or parent/guardian understands that it is his/her responsibility to consult with his/her primary health care provider prior to participating and should the client or parent/guardian choose not to consult his/her health care provider, the client or parent/guardian accepts full responsibility waiving all rights to liability or any claims against Concetta Kirschner, any of its agents, administrators, or employees. The client or parent/guardian attests to the fact that the client or parent/guardian has disclosed all relevant information regarding his/her physical, emotional or mental conditions that could cause harm to the client by participating in these programs. The client, his/her parent/guardian, his/her heirs, or legal representatives forever release, waive, discharge and covenant not to sue Concetta Kirschner, for any injury, harm or death caused by either negligence or other acts. The client or parent/guardian has read and understood this form and all its contents, and the client or parent/guardian voluntarily agrees to the terms and conditions stated above. Confidentiality: The client understands that information will be held as confidential unless the client states otherwise in writing. If the client reports child or elder abuse or neglect or threaten to harm oneself or someone else, the client understands necessary actions will be taken and my confidentiality agreement limited in this capacity. Furthermore, if Concetta Kirschner is ordered by a court to provide information or to testify, she will do so to the extent the law requires. Additionally, the client understands that the use of technology is not always secure and accepts the risks of confidentiality in the use of email, text, phone, Skype and other technology.
Client’s Signature (or parent/guardian if minor) ________________________________________________
Life Coach’s Signature Date _____________________________________________________________________________________