ERM Coaching

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Form: Agreement

Agreement Form

(Note: The coaching world refers to a person being coached as the “coachee,” a convention followed in the remainder of this document.)

Name
I understand that:
In ERM™ Executive Coaching (the “Coaching”) sessions, a certified ERM Coach (the “Coaches”) partners with the client in a creative and thought-provoking process for the purpose of inspiring the client towards fulfillment of his or her expressed goal(s) or objective(s) related to maximizing their personal and professional potential(Required)
The Coaching goals or objectives could include (but are not limited to) career development, relationship enhancement, spiritual growth, lifestyle management, life balance, decision-making, and achieving short-term or long-term goals.(Required)
The Coaching may use inquiry, reflection, discussion, exercises and other approaches to help clarify issues and inspire progress towards the client’s goal(s).(Required)
I understand that the Coaching is not therapy, counseling, advice-giving, mental health care, or treatment for substance abuse. In these sessions, the Coaches (including Dr. Lonsdorf who is a licensed medical doctor), are not functioning as licensed health professionals, and the Coaching is not intended as a replacement for counseling, psychiatric interventions, treatment for mental illness, recovery from past abuse, professional medical advice, financial assistance, legal counsel, or other professional services. The Coaching is for people who are basically well-adjusted and emotionally healthy who wish to maximize their personal and professional potential.(Required)
If I am currently in therapy, have a history of mental illness or are taking (or have in the past taken) medication for mental or emotional health, I agree to inform the Coaches prior to the first session so that the appropriateness of Coaching for me at this time, as well as the distinctions between coaching and therapy, can be clarified.(Required)
I agree that I will not suspend medical or psychiatric treatment on the basis of the Coaching, but will consult with my prescribing physician or therapist before making such changes under his or her supervision.(Required)
The effectiveness of the Coaching requires that both the Coaches and the client are honest and straightforward in their communication. I agree to be honest in my communications, both written and verbal, on the basis of the understanding that we will coach only on those topics that I wish to address.(Required)
I represent that I am fully responsible for my own life and decisions and accept full responsibility for such decisions, including decisions regarding issues discussed in the Coaching.(Required)
Coaching sessions may be emotionally, personally and physically challenging. I agree to let the Coaches know if such challenges become uncomfortable at any time so that appropriate adjustments can be made.(Required)
The Coaching will take place in person, by telephone, over Zoom, by Skype or as otherwise agreed upon. Both parties will be diligent and prompt for sessions in order to make the most of the time together. If either party must cancel or re-schedule, it will be done so with as much notice as possible. I agree to pay any cancellation fees according to the payment terms I was informed of at the time of initiating the coaching sessions(Required)
Coaching is a confidential relationship. The Coaches agree to keep all information strictly confidential, except in those situations where such confidentiality would violate the law.(Required)
I hereby acknowledge that no claims or guarantees have been made to me in any way in connection with the Coaching regarding achieving any specific goals, objectives, benefits or improvements in my life, career, business or health condition.(Required)
I understand that research on coaching sessions like mine may contribute to the success and wellbeing of others with similar goals. I, therefore understand and agree that my client history, narrative reports of coaching sessions, and results from the coaching may be used in research, journal articles, books, or other literature on a no-name basis where my information is “de-identified,” and my identity and identifying information are changed to make them unrecognizable.(Required)
I agree that I have read and agree to the coaching payment fees and information sheet provided to me. I understand that the deposit is non-refundable if cancelling less than two weeks in advance. I understand and agree that full payment for each coaching day is due at the time of service and will be charged to my credit card in accordance with the payment information sheet provided prior to the coaching, unless other arrangements have been made in writing in advance.(Required)
Choice of Law and Venue. This Agreement shall be governed by the laws of the State of Iowa and any action or proceeding in connection with this Agreement shall be brought in any court of record of the State of Iowa, County of Jefferson, or in the United States District Court for the Eighth District of Iowa.(Required)
I understand that giving feedback on the survey forms provided or by email is important to the coaching process and I agree to fill out the various feedback questionnaires as requested.(Required)

While all Skype and Zoom account communications are encrypted, they are not considered a secure patient web portal according to HIPAA standards. No guarantee can be made that the service protects users’ data or the content of communications or that it is secure from third-party “hackers.”

Also, our online surveys (in “Survey Monkey”) for coaching feedback, while in a password-protected account, may not meet HIPAA security standards and are potentially hackable.

I understand I may use initials or a code name when I fill out the name fields on the survey. I understand that E-mail is not a secure and confidential method of communicating personal health or other information.

While Dr. Lonsdorf and her staff take reasonable precautions with the information under their control, interception or misuse of client communications over Zoom, Skype, online forms or email, while unlikely, are possible. I, the client, agree to assume the risk and accept the consequences of such breaches.

HIPAA Standard Disclosure(Required)
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