Coaching Client Consent Form
Name of Student-Trainee: Kimberly Errigo

You have been invited to participate as a volunteer coaching client for a student enrolled in academic courses at Saybrook University, Oakland, CA, under the teaching of Dr. Carleen Phelps, PhD. Your participation is voluntary and you are free to withdraw your consent and discontinue participation at any time.

Definition of Wellness Coaching: Wellness coaching is a facilitated process that empowers clients to make meaningful change and progress toward their desired health and well-being goals.

Purpose of Practice: The purpose of this coaching practice session is to allow the student-trainee to master advanced coaching skills and interventions necessary to conduct professional wellness coaching. You will be invited to participate in a coaching session/s, in which the coach will provide wellness coaching. Please phone or email the below contacts if any conduct takes place that you feel is invasive or improper.

The student-trainee coaching practice is not intended to serve as a form of diagnosis or treatment for any illness or medical condition.

Risks of Coaching: Coaching is a non-invasive process considered generally safe. It is possible that coaching will produce some temporary anxiety or emotional distress during the coaching sessions. We request that you advise us anytime you feel any discomfort so corrective steps may be taken to alleviate your discomfort.

You have the right to ask questions of the student-trainee, and to decline to carry out the coaching session/s and to terminate the activity.

Confidentiality: Your responses in this coaching session are confidential. Information you disclose during coaching will be shared only with the faculty and students in the class, not with anyone else. Your information will be disclosed only as needed for your student-trainee to discuss the coaching practiced and your response, with the student’s instructors and mentoring group. You have the right to identify any information you specifically wish not to be discussed, and your request will be respected. You may also refuse to answer any question(s) that might make you feel uncomfortable. With your permission, your coaching session may be recorded for training purposes and shared with the course instructor and student peers. If you do not want your name disclosed in any discussion of the student-trainee’s practice sessions, please select that option below.

Legally required disclosure of information is rare in coaching. However, should you disclose that you are a risk to your own safety or that of others, your coach may be legally required to disclose that risk, for your protection or that of others.

Right to Terminate Participation: You are free to withdraw from the coaching session at any time without any negative consequences for yourself.
Name of Coaching Client *
Your answer
Gender: *
Email address: *
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Client Permissions
All session recordings, client documentation, and class discussions are strictly confidential.
Permission to record coaching sessions: *
Permission to be added to Kimberly's Client Coaching Log for credentialing purposes: *
Permission for your session recording to be used for credentialing purposes: *
Permission for anonymity during training class: *
Signature Required
Please sign below to indicate that you have read this consent form. The nature, demands, risks, and benefits of coaching have been explained to you, and you agree to participate as described. Should you wish to raise any questions about your student-trainee’s actions, you may call the Dean of the College of Integrative Medicine and Health Sciences at Saybrook University: Donald Moss, Ph.D., 616-842-1277 or email at dmoss@saybrook.edu.
By typing your name below you are adding your electronic signature to this document. *
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