Client Information and Agreement
My name is Mark Csabai. I can be contacted by telephone at 082 825 5873 or online at www.mindinmotion.co.za.
Or send an email at email@example.com.
Education and Training:
I was trained as a Certified NLP Practitioner at the American Union of Neuro-Linguistic Programming. I am also a certified New Insights Life coach. I have over twenty years of experience. I do annual continuing education to maintain my training at a high level.
Notice: As an alternative health practitioner, I am not licensed as a psychologist or mental health provider. My services are considered complementary to regular medical and psychiatric care. Would you please discuss medical or psychiatric concerns with your physician or mental health provider?
Your Client Rights:
If you, the client, desire a diagnosis or any other type of treatment from a different practitioner, you may seek such services at any time. If you terminate my services, you have the right to coordinate the transfer of services to another practitioner. You have a right to refuse my services at any time. You have a right to be free of physical, verbal, or sexual abuse from me. You have a right to know the expected duration of treatment and may assert any right without retaliation.
The charges for my services are R500 per hour, depending on the coaching offered. Fees are due and payable at the time of service.
I accept cash or EFT (Electronic Finance Transfer)
My banking details are Mark Laszlo Csabai, FNB, Cheque Account, Account Number: 62157234156, Branch Code: 230234.
I will not release any information to anyone without written authorization from you, except as provided for by law. You have a right to access my written record about you.
I approach issues with the fundamental concept that you, the client, are not broken and have all the resources to resolve your problems yourself. Therefore, I view my position in our relationship as an educator and process facilitator to assist you in connecting with your internal resources to resolve your challenges.
As the process facilitator, I will determine which processes or educational assets to use and apply such methods or education as I deem appropriate. Your responsibility will be to cooperate with such methods and follow through with subsequent assignments to the best of your ability.
No guarantee can or will be given as to the outcome of your coaching. You are entitled to bring a colleague to coaching sessions for support should you wish
By my signature below, as the client, I am signifying that I am willing to accept the coaching, techniques, and processes offered to me for vocational, avocational and self-improvement. I understand that the services I receive are not a substitute for regular medical care and are, as a result of this, advised to discuss medical services with my physician. Finally, I agree to accept full responsibility for my choices and experiences and release Mark Csabai from liability.
Finally, I acknowledge that I will be charged R100 for each session for which I fail to appear and give at least 24 hours’ notice.
I have received, read and understand this Client Information and Agreement.
Client Name (print):______________________________________________________________
Client Signature: _________________________________________________________________