Medical information form for Integrative Coaching Interventions
Integrative coaching is intended for personal growth, stress management, self-mastery, emotional well-being and an approach towards self-realization. This coaching approach may involve processes that may not be appropriate for pregnant women, or for persons with cardiovascular problems, severe hypertension, severe mental illness, recent surgery or fractures, acute infectious illness, or epilepsy; and may activate intense emotional experiences which can continue beyond the time of the session and for which other support may be required. For the safety of clients, coaches reserve the right to refund individual fees and cancel the coaching session due to contraindications including, but not limited to, those listed below.

Client further agrees that it is the Client’s responsibility to maintain the accuracy and contemporaneousness of the Medical Information Form. Coaches will assume that Client's Medical Information Form is correct until Client files an updated or corrected form.

If you have any doubt about whether you should participate, consult your physician, psychiatrist or medical professional, as well as your coach before. Please answer all questions as completely as possible.

1. Do you have a history of, or currently suffer from any of the following?

Client Disclosure If you are in therapy or medical treatment with a licensed health care practitioner (“Health Care Provider”), you need to present Integrative Coaching with a letter of referral from such Health Care Provider before we start the coaching program. If you have been prescribed medication to take by the Health Care Provider, you need to present Integrative Coaching with a letter of consent from Health Care Provider before we start. This means a short-written note stating that you have informed your health care provider of your decision to engage in Integrative Coaching.

Your Choice, Your Responsibility During the life coaching program Integrative Coaching will offer you advice and other ways of looking at your problem and solutions for your consideration. Whatever we discuss is only Integrative Coaching’s perspective and is not binding upon you, nor is it a prescription. If you want to discuss Integrative Coaching suggestions with someone else, you should discuss them with a licensed health care provider. It is your responsibility to confirm whether or not any changes we made produced the desired results. It is your responsibility to communicate your results to Integrative Coaching. By signing this disclosure you confirm that you have read and understood it clearly and accept your responsibility to comply with disclosing any information determined relevant by this disclosure.

PLEASE READ FOLLOWING STATEMENT CAREFULLY

I, the Client (as defined in Section1 above) hereby confirm that I have read and understood the above information and have answered all the questions completely and honestly, and have not withheld any information. My general health, as far as I’m aware, is good. I understand that it is my personal responsibility to inform Integrative Coaching of any changes to my medical history during the course of my coaching process and confirm that should this occur I shall advise Integrative Coaching of any changes. During a Breathwork session, I understand that body work may be performed only if specifically requested. If I do not want body work done, or if I want bodywork being done to me to stop, I will say “Stop - I mean it!” in order to indicate to the coach what my needs are. I understand that it is my responsibility to speak up for myself, and I am able to do that.

I confirm that I have been given the opportunity to ask questions and that I have read and fully understood the contents of this consent form.

Client Commitment Agreement

I, the Client (as defined in Section 1 above) on the date of signature hereof hereby choose to agree and commit to:

• Time: What is termed a full session is 50 minutes; half sessions are 30 minutes. The coaching schedule will be on a predetermined cyclic basis for session time, in person, skype or telephonically (by mutual agreement). The frequency of sessions may be predetermined or on a session by session basis.
• Cancellation Policy: If Client needs to cancel and/or rearrange a coaching session, Client should provide at least 24-hour notice. No refunds will be given to Clients for unused coaching sessions unless 24 hours’ notice has been given.
• Participation: Coach will be fully present and listen without judgement, and give the very best on what coach has to offer. Client promises to show up and be open to our coaching sessions. This also means cell phones to be turned off unless there’s an emergency.
• Taking Action: Client agrees that the Coach may assign tasks to be done in between coaching sessions, and that Client will give best effort to fulfil them. Client further agrees that if tasks are not done the outcome of the coaching is impacted. Client understands that the results of any coaching will depend on Client ability to take action and to follow the coaching to the best of Client abilities, communicate clearly with the Coach, and to take responsibility for the results achieved and the Coach can only facilitate. The responsibility for making the processes work is the Client’s alone as no one else can do them for her/him.
• Coaching Plan: Coach and Client will jointly develop a coaching direction based on the Client’s outcomes for coaching. Coach agrees to facilitate and Client agrees to follow the coaching plan.
• Confidentiality: All information supplied by the Client in coaching sessions will be treated as confidential. It will not be disclosed to a third party without the client’s prior written consent, save where required by law or where action might be necessary to prevent harm to the Client or someone else.
• Integrity: Living a life you love is only possible if you live with integrity. If for any reason the client cannot honour this or any other agreement we have together, then it is up to the client to let the coach know.
• Fees: Fees will be discussed with client prior or during the intro session. Client agrees to pay coach session fee under this agreement until cancelled. Client agrees to pay for coaching sessions per session, in bulk or monthly in advance via EFT and emailing proof of payment.
• Disclosure: Client agrees to share with Coach all issues on which Client needs assistance. Client agrees that issues not shared with Coach may not be resolved or may impede the successful achievement of his goals and objectives.
• Termination: This agreement starts from the first paid appointment and will continue until termination. In case of terminate, there should be time for a closing session to make sure that all loops are closed.
• Domicilium: Client hereby chooses its domicilium citandi et executandi for all purposes arising out of this agreement, the address set forth in Section 1 above and undertakes to notify Integrative Coaching forthwith in writing of any change of address.
• Breach: Save as may be expressly provided to the contrary in this Agreement, either party may terminate this Agreement in the event that the other party:
  • Fails to pay any amount validly due hereunder;
  • Breaches any material term of this Agreement and such breach is incapable of remedy or, if the breach is remediable, it continues for a period of 30 (thirty) business days after written notice requiring same to be remedies has been given to the party in breach.
• Waiver: Any condonation of any breach of the provisions hereof by the Client, or any other act or relaxation or indulgence on the part of Integrative Coaching shall not in any way be deemed as a waiver by Integrative Coaching of any of its rights that it may have in terms hereof or by operation of law, or be construed as a novation thereof.
• Governing Law: This Agreement shall be governed by and construed in accordance with the laws of the Republic of South Africa.
• Severability: Every provision of this Agreement is deemed to be separate and severable, and should any provision be found to be defective or unenforceable for any reason, that provision will be severed from the remaining provisions and the validity of the remaining provisions shall continue to be of full force and effect.
• Entire Agreement: This Agreement contains the entire agreement between the parties and any other terms thereof whether express or implied are excluded herefrom and any variations, cancellations or additions to this contract shall not be of any force or effect unless reduced to writing and signed by the parties or their duly authorised signatories.
• Consumer Protection Act 2008 (as amended) (“CPA”): No term or condition of this agreement, which includes all the sections attached hereto (“Agreement”) is intended to breach any peremptory provisions of the CPA and the regulations promulgated from time to time under the CPA ("Prohibited Provision"). If for any reason any part of this Agreement is in breach of any such Prohibited Provision, such paragraph, clause, term and provision shall, to that extent, be deemed not to form part of this Agreement, and the severing if such paragraph, clause, term and provision shall not impair the operation of, or have any other effect upon, such other portions of this Agreement as may remain intelligible, which shall continue to give full force and effect and bind the parties thereto.
• The following provisions are drawn to the attention of the Client if the CPA applies to this Agreement:
  • Paragraph 5 of Section 2 above:
    • contains a waiver from the Client to Integrative Coaching in respect of any activities, results, injuries, loss, damages, harm, costs, expenses and/or other claims of whatsoever nature that may arise directly or indirectly during or from the coaching process. The effect of the waiver is that the Client may have no claim against Integrative Coaching in the stated circumstances;
    • provides that Integrative Coaching makes no warranties, promises or representations regarding the outcomes of the coaching and Integrative Coaching. The effect of this is that the benefit to the Client of any common law representations or warranties is excluded;
• If the CPA applies to a Transaction Document, Coaching may not impose a cancellation fee in respect of booking or reservation if the Client is unable to honour the booking or reservation because of the death or hospitalization of the person fir whom, or for whose benefit the booking or reservation was made
• If the CPA applies to the Agreement:
  • and the Client is a natural person Integrative Coaching may not cancel the Agreement, if the Client has committed a material breach of any obligation under this Agreement unless it has first given the Client 20 (twenty) Business Days written notice to remedy any material breach and the Client has failed to remedy such material breach within such period;
  • the Client may terminate the Agreement in accordance with any provision of the CPA permitting the same.

Warning
Please consider entering this agreement carefully. Signing this agreement is a clear message to your unconscious mind that you are serious about the life you want. Any breach of this agreement will constitute a message that you are not serious about the life you want to your unconscious mind. A confused mind is very unproductive and can cause you to get exactly the same results that you are used to. Yes, those same results that caused you to be considering entering into this agreement in the first place. Whatever you decide now will give you results. Consider the results you want and know that by signing you're choosing the life you want.