Please complete this agreement, review the terms, sign & fax to 303-627-1684. Thank you!

Client Data
Name:  ________________________________________________
Address:  ________________________________________________
Day Phone:  ________________________________________________
Evening Phone:  ________________________________________________
Fax:  ________________________________________________
Email:  ________________________________________________
Children (Names & Ages):  _________________________, _________________________
Partner’s Name:  ________________________________________________
Birthday:  ________________________________________________
Occupation/Employer:  _________________________, _________________________

Coaching Terms:
Fees:    $455 for three sessions per month or $152.00 per session.
Duration of session:    Forty-five (45) minutes per session
Session Day:    Monday    Tuesday    Wednesday
Session Time:    am    pm    PT    MT    CT    ET    other____________

Procedures:
❍ I will contact you for our sessions.
❍ If I cannot reach you, I will attempt to contact you a second time after 5 minutes.
❍ After the third attempt, If I am unsuccessful, your session will be terminated and you will be billed for missing your session.

I understand that Pamela C. Chapman is not a licensed therapist and that I am responsible for all my decisions, actions and feelings.

Client Name:  ________________________________________________
Date:  ______________________________