Healthcare Coaching Contract

HEALTHCARE COACHING CONTRACT

Parties and Effective Date

This Healthcare Coaching Contract (the "Agreement") is entered into by and between:

Client Name:

Coach Name / Organization:

Effective Date:

Recitals

The Client desires to engage the Coach to provide healthcare coaching services described herein, and the Coach agrees to provide such services subject to the terms and conditions of this Agreement. The parties acknowledge that coaching is not psychotherapy or medical treatment and that the Client retains responsibility for medical decisions.

Scope of Services

The Coach will provide individualized healthcare coaching, including goal setting, behavior change planning, lifestyle and wellness guidance, progress review, and coordination with other providers as authorized. Specific services and limitations are described below.

Session Length:    Frequency:

Term and Termination

Term: This Agreement commences on the Effective Date and continues until , unless earlier terminated in accordance with this Agreement.

Termination: Either party may terminate for any reason with fourteen (14) days' written notice. Coach may terminate immediately for Client's nonpayment, material breach, or safety concerns. Termination does not relieve Client of payment obligations for services already rendered.

Fees, Billing, and Payment

Fee per Session: $    Package Fee (if applicable): $

Cancellation and Rescheduling

Client must provide at least 24 hours' notice to cancel or reschedule. Cancellations with less than 24 hours' notice may be charged the full session fee unless otherwise agreed. Exceptions may be made for emergencies at Coach's sole discretion.

Confidentiality and HIPAA Authorization

Coach will maintain the confidentiality of Client information consistent with professional coaching standards and applicable law. To the extent Coach maintains protected health information as a business associate or covered entity, Client authorizes disclosure and uses as required for care coordination and payment as described below.

I authorize the Coach to use and disclose my protected health information for purposes of coaching, coordination with my medical providers, and billing as necessary.

Authorization expires on:

Limitations; Not a Substitute for Medical Care

The Client acknowledges that coaching is educational and supportive and is not medical care, psychotherapy, or emergency response. The Coach does not diagnose or prescribe. Client must seek or continue care from licensed healthcare professionals for medical conditions. In the event of a medical emergency, Client will call emergency services immediately.

Client Responsibilities

Coach Responsibilities

Emergency and Crisis Protocol

Coach is not responsible for emergency response. If Client is in imminent danger or experiencing a medical or psychiatric emergency, Client must call emergency services. If Coach believes Client presents an imminent risk of harm, Coach may contact emergency services or emergency contacts listed below.

Liability, Indemnification, and Insurance

Client acknowledges that coaching involves active participation and that Coach makes no guarantees. To the maximum extent permitted by law, Client releases and holds harmless Coach from liability related to coaching services except for willful misconduct or gross negligence. Client agrees to indemnify Coach from third-party claims arising from Client's actions.

Dispute Resolution and Governing Law

The parties shall attempt in good faith to resolve disputes through informal negotiation. If unresolved, disputes will be submitted to binding arbitration under the laws of the state selected by Coach unless otherwise required by law. Venue for litigation, if any, shall be the courts of the governing jurisdiction selected below.

Governing Law:

Miscellaneous

Entire Agreement: This Agreement contains the entire understanding of the parties and supersedes prior agreements. Amendments must be in writing signed by both parties. If any provision is held invalid, remaining provisions remain in force.

Patient Information

Female Male Other / Prefer not to say

Insurance Information (Optional)

Medical History

Consents and Authorizations

I consent to receive coaching via telehealth, video conferencing, telephone, and electronic communication when in-person is not available. I understand privacy risks and accept them.

I consent to receive appointment reminders and messages via phone, SMS, and email. Standard messaging rates may apply.

I authorize the Coach to share relevant information with my healthcare providers for care coordination, as necessary.

Acknowledgment

By signing below, Client acknowledges that they have read and understand this Agreement, that coaching is voluntary, that they have provided accurate medical and contact information, and that they consent to the services and policies described herein.

Sign Now