Client Agreement
Please fill in this form before we begin working together.
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Email *
Full Name (first name followed by surname and any mode of address you wish to share with me) *
Contact phone number *
Address (including postcode) *
Please tell me how you heard about me
Please give a short description of what you would like to achieve through Coaching/Mentoring or facilitated conversation *
Do you have any fears, concerns, medical conditions or special needs that could impact our work together? *
If you have answered 'yes' or 'maybe' above, please say more (or skip to next question if your answer was 'no')
By working with me you agree to the following statements. Please tick each box to show you have read and agree to them. *
Data Protection
Any registration information and session notes are stored electronically encrypted on my computer. You can request complete copies of the records I hold, at any time. I will keep the content of our sessions and your personal details and data, private, to the extent permissible by law. You can read my privacy policy and terms and conditions at
Safe Guarding
As with all my clients if I think a child is at risk of harm or your life is in danger, I would firstly speak to you about my concerns. If I continued to be concerned, I would refer my concerns onward to a relevant contact (which could be a legal authority if my concerns escalated or it was my legal duty), for extra support.
I understand that disclosures during a facilitated dialogue maybe made for the purpose of attempting to reach an agreement and on the basis that they are confidential. This means they are without prejudice and legally privileged and will NOT be referred to in evidence in any formal process or legal proceedings about the same issues. Any disclosure or content of the conversation will not be used in affidavits or statements. Please tick below to acknowledge that you agreement to the above statement. *
I will not call Tracy Seed as a witness, nor require her to produce in evidence of any records or notes relating to facilitated dialogue sessions, in any litigation or other formal or informal legal process arising from or in connection with the issues being considered. If a court or tribunal orders the mediator to give evidence, attend court or disclose documents, you will fully indemnify Tracy Seed in respect of any costs, fees or expenses, including legal costs, incurred in resisting or responding to such an application. *
Is there anything else you want me to know?
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