Consultation Request/Agreement Form

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Email *

Email Address *

Full name *

Direct contact number *

What are your general purpose that you would would like to book Samaria for a consultation meeting for? *

1. This agreement is for consultation and is not an agreement for counseling or a therapeutic treatment or services. This is a professional peer to peer consultation interaction. If I am in need of a therapist or counseling services I agree to seek an alternative resource within my local community. *

I understand

2. Terms of Payment: The cost of each consultation session is 450. per session. Sessions last for 60 minutes. 30 min sessions are not offered. There is no refunds. Payments must be completed at least 24 hours prior to my session or my scheduled session will be canceled. *

I understand

3. Forms of payment include credit cards. Samaria M Colbert does not take alternative forms of payment such as cashapp, cash or checks. If your credit card is declined, you will need to submit an alternative card at least 24 hour prior to your appointment or it will be canceled. *

I understand

4. Release and Waiver of Liability: I have voluntarily agreed to consultation with Samaria M Colbert. I hereby unconditionally release and forever discharge any persons, including Samaria M Colbert from any liabilities, damages, losses, expenses, claims or demands, from this consultation agreement. This document is a release of all liability, and contracts against Samaria M Colbert in court of law. I agree to a consultation professional interchange at my own free will. *

I understand

The consultation is NOT clinical supervision. If I am in need of a clinical supervisor I agree to find one with in my local area. *

I understand

5. It is the client's responsibility to keep up with their appointment. Meetings are to start on time, if the client is 15 minutes late or more to the appointment, the consultation session is canceled. There are no refunds issued. *

I Understand

6. There is no recording allowed in the consultation session. *

I understand

7. Confidential Information For purposes of this Agreement, “Confidential Information” shall include all information or material that has or could have commercial value or other utility in the business in which Disclosing Party is engaged. If Confidential Information is in written form, the Disclosing Party shall label or stamp the materials with the word “Confidential” or some similar warning. If Confidential Information is transmitted orally, the Disclosing Party shall promptly provide a writing indicating that such oral communication constituted Confidential Information. *

I Understand

Although we certainly understand that the nature of the consultation is to assist the individual. We do not guarantee that upon completion of the consultation relationship you will have your own practice/business or other purpose for booking the consultation session as the timing, process and procedure to completion is solely up to the potential clinician/business owner. *

I understand

Although we certainly understand that the nature of the consultation is to assist the individual. You understand building a practice should be unique to you. Therefore you agree not to build a practice that is the EXACT same as Samaria M Colbert, or Kingdom Creative Counseling PLLC. You are not free to replicate or copy the organization, or Samaria M Colbert's businesses. That includes having the similar or same LOGOS, Statement of purpose, websites or any statement that would suggest copyrighting her information, business or work. *

I understand

I have read the Terms and Conditions of the consultation agreement, and acknowledge that I am bound to the terms and conditions set forth in the agreement. I acknowledge that I am entering into the agreement voluntarily. If you agree type your full name below: *

Today's Date

YYYY

What happens next? After the individual submits the necessary information. Your consultation is not approved yet. It will be sent to Samaria for review. If the consultation is not completed fully or there is some discrepancy it will be sent back to you. Your consultation will be either approved or denied. If approved your meeting request will be accepted, and an invoice will be emailed to you that must be paid at least 24 hours prior to your appointment. *

I Understand

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