Agreement For Coaching for Mind-Body Balance

Coaching for Mind-Body Balance
Authorization and Agreement

I understand and agree that:

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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, emotionally healthy, and functioning effectively, but who want to make changes in their lives.*
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 can be discussed. If I am in therapy, I understand that a letter of approval from my therapist may be required before the start of the Coaching.*
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.*
Coaching for Mind-Body Balance (the “Coaching”) is a relationship in which Nancy Lonsdorf MD and/or her designated consultant (the “Coaches”) meet with the client in a session or series of sessions for the purpose of helping the client make progress towards his or her expressed goal(s) or objective(s). Client’s goals for the session(s) are expressed in advance and agreed to by Dr. Lonsdorf.*
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.*
The Coaching may use inquiry, reflection, discussion, exercises and other approaches to help clarify issues and promote progress towards the client’s goal(s).*
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 communication.*
Any comments made by the Coach regarding aspects of my physical, mental or emotional health, my body and its physiological functioning I understand are meant for educational purposes and are not diagnostic of the presence or absence of disease. I agree to consult with my personal physician outside of the session for further evaluation of my mental, physical or emotional health issues.*
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.*
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.*
The Coaching will take place in person, by telephone, 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.*
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.*
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 or health condition.*
Data of any surveys or narrative report of the benefits I receive from the consultation may be used in research or promotional materials, but that my name will not be used without my consent.*
I understand that research on coaching sessions like mine may contribute to the health and well being of others with similar concerns. I, therefore, understand and agree that a confidential recording may be made of my coaching sessions, and that my client history, narrative reports of any 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 identity and identifying information are not disclosed (unless I provide a written consent for my identity to be disclosed).*
I understand that the Coaching is not a program of Maharishi Ayurveda, Maharishi Vedic Education Development or any other official Maharishi trademarked program.*
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.*
I understand that the number of requisite coaching hours to achieve the desired results is highly variable and that I have not been guaranteed or represented a particular number of coaching hours to resolve my issue(s) or achieve my particular goal(s). I also understand that results may vary as a result of the coaching sessions and no specific results are promised or guaranteed.*
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.*
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.*

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

Also, online surveys 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 information.

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

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Nancy K. Lonsdorf, MD
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