Personal Journal Form

PERSONAL JOURNAL FORM

Agreement Parties and Effective Date

Provider Name:     Client Name:

Effective Date:

WHEREAS

WHEREAS, Provider is engaged in the business of facilitating, curating and providing guidance for personal journaling, reflective exercises, and related written materials; and

WHEREAS, Client desires to participate in Provider's journaling programs and to submit written journal entries for review, coaching, storage, or other mutually agreed services; and

WHEREAS, the parties wish to set forth the scope of services, payment terms, confidentiality obligations, and other terms governing Provider's handling of Client journal entries and related services.

Scope of Work

Payment Terms

Fee Amount:

Late fee or interest rate applied to overdue amounts:

Term and Termination

Term Start Date:     Term End Date:

Either party may terminate this Agreement by providing written notice to the other party at least days prior to the desired termination date. Provider shall be entitled to payment for services performed and expenses incurred through the effective date of termination.

Confidentiality

Provider acknowledges that journal entries, reflective notes, sensitive personal information, and related materials submitted by Client are confidential information. Provider agrees not to disclose Client's journal content to any third party except as required by law, except with Client's prior written consent, or to the extent necessary for Provider staff directly engaged in performance of the Scope of Work. Provider will implement reasonable administrative and technical safeguards to protect the confidentiality and integrity of stored journal entries.

Client acknowledges that selective sharing (e.g., designating specific entries for Provider review) may be required for coaching services. Client authorizes Provider to access entries marked as shared by checking the consent box below.

  I consent to Provider accessing and reviewing journal entries specifically marked by me for review.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of law principles.

Entire Agreement

This Agreement, together with any written attachments or schedules signed by the parties, constitutes the entire agreement between Provider and Client with respect to the subject matter herein and supersedes all prior and contemporaneous agreements, proposals, representations and communications, whether oral or written.

Personal Journal Entry (Fill for each entry)

Entry Date:     Entry Title:

Happy    Sad    Anxious    Calm    Other:

Would you like this entry available to Provider for review under the terms above?   Yes

Acknowledgment and Certification

By signing below, each party certifies that they are authorized to enter into this Agreement, that the information provided herein is true and accurate, and that they consent to the collection, storage, and limited use of journal entries as set forth in the Confidentiality section. Client understands that journaling is not a substitute for professional medical or mental health care and agrees to seek appropriate professional services where necessary.

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