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You can print this form, fill it out, and mail the signed hardcopy to the address below,
or bring it to your first appointment to sign together.
1945 Pauline, Suite 10
Ann Arbor, Michigan 48103
Agreement for Counseling/Coaching
- I have read and agree to be bound by the professional disclosure statement
of Melanie Fuscaldo. This statement informed me of
what the counseling/coaching process involves, my rights and the fees per
- Melanie and I together will determine the scheduling and duration of
- I understand Melanie will maintain the confidentiality of our discussion
within the session unless she is required by law to share any information. She
may share information about our sessions with professional colleagues for the
purpose of aiding me in my development. If I would like Melanie to share
information with another professional I will sign a release form. She may also
ask me to sign a release form if she wants to share information with
professionals. When it is legal we both have the right to deny information
sharing to certain professionals.
- I understand Melanie will provide counseling/coaching not job placement
services. Melanie will in no way be liable for my plans or satisfaction.
- I have voluntarily chosen to participate in counseling/coaching.
- I have the option at any time to request a free meeting to discuss any
problems in my working relationship with Melanie. Melanie also has the option
to request a free problem consultation meeting.
- I understand that fees are due at time of service. Checks or cash are accepted.
Since my established appointment has been reserved for me, missed or canceled
appointments require a 24 hour notice or I will be charged for the session.
Cancellations must be communicated by phone, not by email.
Client signature & date:
Counselor/Coach signature & date: