Personalized Care Agreement

You’ve had your discovery session and/or have a plan for your Personalized Care. Let’s confirm we are all on the same page.

Filling out this form helps confirm the logistics of your Personalized Care and ensures that you understand how we deal with confidentiality.

Name

First Name

Last Name

Email Address

This is the email we should use for billing.

WhatsApp or Phone Number (please do NOT include the "+" sign)

Your Personalized Care Provider's Name

Choose which best describes you:

Standard

Non-Profit

Which package would you like?

One session

Six sessions

Twelve sessions

I have read and understand your confidentiality policy.

I've read and understand the confidentiality policy.

My provider and I plan to start meeting on this date:

YYYY