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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.

Melanie Fuscaldo
1935 Pauline, Suite 200
Ann Arbor, Michigan 48103
(734) 788-7806

Agreement for Counseling/Coaching

  1. 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 session.

  2. Melanie and I together will determine the scheduling and duration of counseling/coaching sessions.

  3. 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.

  4. I understand Melanie will provide counseling/coaching not job placement services. Melanie will in no way be liable for my plans or satisfaction.

  5. I have voluntarily chosen to participate in counseling/coaching.

  6. 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.

  7. I understand that fees are due at time of service. 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, text or email.

Client signature & date: Counselor/Coach signature & date: