ADHD Coaching for ChildrenPlease fill out this form and click submit. I’ll be in touch with you shortly after submission. Name (Parent) * First Name Last Name Name (Child) * First Name Last Name Age (Child) Email * Phone * (###) ### #### Please list three of the child's strengths / interests For example: drawing, music, sport, languages, social skills Please choose out of these options which topics you would like your child to learn more about to support them in understanding their ADHD. Self Management Strategies Social Skills Self Esteem Friendships and Conversations Organisation and Time Management Navigating complex feelings (overwhelm, nervousness, anxiousness, procrastination) Skill building (problem solving, boundary setting, transitioning) I have read the coaching disclaimer * understand that the coaching services I will be receiving from my Coach are not offered as a substitute for professional mental health care or medical care and are not intended to diagnose, treat or cure any mental health or medical conditions. I also understand that my Coach is not acting as a mental health counsellor or a medical professional. For legal purposes, I understand that coaching is currently an unregulated industry and that my Coach is not “licensed” by any Australian body even though the sessions may take place in Australia. I understand and agree that I am fully responsible for my well-being during my coaching sessions, and subsequently, including my choices and decisions. I understand that coaching is not a substitute for counselling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy. I understand that all comments and ideas offered by my Coach are solely for the purpose of aiding me in achieving the defined goals I create with my Coach. I am able to give my informed consent, and hereby give such consent to my coach to assist me in achieving such goals and understand that results are not guaranteed. I understand that to the extent our work together involves family, education, career or business, my Coach is not promising outcomes included but not limited to increased personal success. I understand that my Coach will protect my information as confidential unless I state otherwise in writing. If I report child, elder abuse or neglect or threaten to harm myself or someone else, I understand that necessary actions will be taken, and my confidentiality agreement limited in this capacity. Furthermore, if my Coach is ordered by a court to provide information or to testify, she will do so to the extent the law requires. I understand that the use of technology is not always secure and accept the risks of confidentiality in the use of email, text, phone, Zoom and other technology. I understand that I may terminate or discontinue the coaching relationship at any time. I hereby release, waive, acquit and forever discharge my Coach, any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages I may claim to have or that I may have arising out of acts or omissions by myself or by my Coach as a result of the advice given by my Coach or otherwise resulting from the coaching relationship contemplated by this agreement. I further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents. Yes, I have read the coaching disclaimer Terms & Conditions * The number and frequency of coaching session will be agreed at the start of coaching, alternatively, if no specific number is agreed sessions will be provided on a session by session basis. In return for the fees payable by the client (or by a third party on their behalf), I agree to provide the coaching service as described in accordance with the terms and conditions set out herein. The date that the first coaching session takes place shall be deemed to be the start date for the service. Where any client is unhappy with any of the terms and conditions, they can contact eliza@adhdwithme to arrange to discuss any concerns and see if they can be resolved before the first coaching session. Participation by any individual in the first coaching session constitutes acceptance of these terms and conditions. SESSION FEES The fee per session is as set out on ADHDwithme.com website at time of booking for a 50-minute session, the 1 hr session slot includes a 10-minute buffer time. The fee is to be paid at time of booking unless, by special arrangement, it will be paid on the day of the session. Payment by credit card on the website is accepted. Where payment has not been received in advance of a coaching session, the session cannot be considered as confirmed and I am not obliged to provide the session. PUNCTUALITY I understand that some of our clients find it hard to be punctual. However, our coaching sessions always run on time. Unfortunately, clients who arrive late will need to have shorter coaching sessions. I am always happy to provide clients with extra scaffolding in the form of additional reminders and prompts to help them deal with this challenge if it occurs. PROCEDURE The coaching schedule will be arranged between the Coach and the Client and can be booked up to 3 months in advance or as per plans offered on the website from time to time. I will recommend the frequency of coaching sessions based on a professional assessment of the client’s requirements. This recommendation, or plan, is not binding and may be altered and adjusted throughout the coaching journey by mutual agreement, in accordance with the terms set out in this agreement. I primarily use Zoom meetings for coaching, unless otherwise agreed. The Zoom invitation will be sent out at the time of website booking, please familiarise yourself with Zoom before our first session. CHANGES Should you need to reschedule your session, please give me at least 24 hours’ notice. If you have an emergency, I will work around it. Late cancellations and ‘no-shows’ will incur the full fee. There may be a time that I am forced to reschedule too, but I will let you know in good time. BETWEEN SESSIONS Activities, tasks and/or exercises may be provided to be completed between coaching sessions. There is no obligation on you to complete these items of ‘homework’, but not doing so may slow your progress in gaining the improvements identified as keys to meeting your goals. CONFIDENTIALITY Coaching sessions are strictly confidential. Unless I have the Client’s permission, I will not discuss our coaching with anyone, including partners, parents, family members or employers. Our client list is also confidential. EARLY TERMINATION In exceptional circumstances, such as illness or unavailability due to bereavement or other commitments, inappropriate behaviour by the Client, actual or potential conflict of interest, or other reasons, I may decide to terminate the service to the Client early or refuse or be unable to provide further coaching sessions to the Client. In such circumstances the Client will be given reasonable notice of termination where practicable and will be refunded any advance payments made for coaching sessions not yet provided. GOVERNING LAW This contract is governed by the law of Western Australia whose courts have exclusive jurisdiction in relation to any dispute, disagreement, proceedings or legal claim of any nature relating to the service provided or the contract. LIMITED LIABILITY Except as expressly provided in this Agreement, the Coach makes no guarantees, representations or warranties of any kind or nature, express or implied with respect to the coaching services negotiated, agreed upon and rendered. In no event shall the Coach be liable to the Client for any indirect, consequential or special damages. Notwithstanding any damages that the Client may incur, the Coach’s entire liability under this Agreement, and the Client’s exclusive remedy, shall be limited to the amount actually paid by the Client to the Coach under this Agreement for all coaching services rendered through and including the termination date. ENTIRE AGREEMENT This document reflects the entire agreement between the Coach and the Client and reflects a complete understanding of the parties with respect to the subject matter. This Agreement supersedes all prior written and oral representations. The Agreement may not be amended, altered or supplemented except in writing signed by both the Coach and the Client. DISPUTE RESOLUTION Should a dispute arises out of this Agreement that cannot be resolved by mutual consent, the Client and Coach agree to attempt to mediate in good faith for up to (certain amount of time such as 30 days) after notice given. If the dispute is not so resolved, and in the event of legal action, the prevailing party shall be entitled to recover attorney’s fees and court costs from the other party. SEVERABILITY Should any provision of this Agreement shall be held to be invalid or unenforceable for any reason, the remaining provisions shall continue to be valid and enforceable. If the Court finds that any provision of this Agreement is invalid or unenforceable, but that by limiting such provision it would become valid and enforceable, then such provision shall be deemed to be written, construed, and enforced as so limited. WAIVER The failure of either party to enforce any provision of this Agreement shall not be construed as a waiver or limitation of that party's right to subsequently enforce and compel strict compliance with every provision of this Agreement. FEEDBACK Feedback about the service is welcomed and can be given during a coaching session or by writing to us at eliza@adhdwithme.com.au Yes, I have read the terms and conditions Thank you! Your form has been submitted and I will be in touch shortly.