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Please feel free to reach out to me at any of these links if you have any additional questions or concerns that were not addressed here.
Email: amhirsch@physiciancoachingwithanne.com
Phone: 503-567-9443
Disclosure, Release, and Waiver of Liability
By signing this Life Coaching Services Disclosure, Release, and Waiver of Liability (the “Agreement”), I understand, acknowledge, and agree to all terms set forth herein, with respect to the services rendered Physician Coaching with Anne, LLC and its employees, consultant, and agents, including, but not limited to, Anne Hirsch (“Coach”).
1. No Medical Care. I am choosing to engage Coach as a life coach only and not for the purposes of medical or psychological care, advise, or treatment. Although Anne Hirsch is a licensed medical doctor, she is not providing me any medical or psychological care, advice, or treatment. I am not and will not be Coach’s patient. She is not and will not be my doctor or mental health professional. I am not engaging Coach for any medical or psychological or healthcare services. I understand that Coach does not and will not diagnose, treat, or claim to cure any medical or psychological or other condition, and that Coach’s services are not designed or intended to replace professional medical or psychological treatment. I am solely responsible for my own healthcare decisions. I agree to seek medical or other appropriate professional assistance or treatment from a duly licensed practitioner if needed. Coach has advised me that she does not admit patients to the hospital or treat hospitalized patients, and that I should maintain a relationship with a physician who is available to provide emergent and urgent care. If I encounter a medical emergency and am not able to obtain care from my primary care physician, I will contact 911 or report to a hospital emergency department. Coach does not provide on-call services.
2. Not Replacing Current Financial Services. Coach is acting in a supportive consultative coaching capacity and not as a financial advisor, certified public accountant, or legal advisor. Accordingly, Coach is not replacing services currently provided to me by certified public accountants, financial advisors, and licensed legal counsel. Coach has advised me that I should maintain a relationship with my certified public accountant, tax advisor, financial advisor, and legal counsel. I will notify my current financial service providers and legal counsel of any changes I choose to make as a result of advice received from Coach.
3. Benefits, Alternatives, & Risks. Benefits of life coaching may include, greater relaxation, ease and feeling of overall well-being. Benefits may also include, but are not limited to, increased profitability, efficiency, and overall satisfaction with my profession and business. Alternatives to life coaching may include self-help techniques and medical or psychological care. Risks of both include distress, mental health issues which require referral to a suitable, licensed healthcare provider, dissatisfaction with results, and over-relying on life coaching notwithstanding recommendations by life coach, when I know I should see a licensed physician, mental healthcare or other professional, to treat a physical or psychological condition. Additional risks can include a decrease in profitability, efficiency, and possible dissatisfaction with my profession and business.
4. No Claims or Guarantees. I understand that Coach makes no representations, claims or guarantees that my medical problems or conditions will be cured, solved, or helped by Coach’s recommendations. I understand that Coach makes no representations, claims or guarantees that my business or current employment status will be benefited or helped by Coach’s recommendations. I understand and acknowledge that Coach has made no implications, warranties, promises, suggestions, projections, representations, or guarantees whatsoever to me about future prospects or earnings, or that I will earn any money, with respect to following Coach’s advice. Any earnings or income statements, or any earnings or income examples, are only estimates of what I could possibly earn but are not guarantees that I will earn the same or similar income. I am advised to do my own due diligence when it comes to making business decisions and I should use caution and seek the advice of qualified professionals. I should check with my accountant, lawyer, or professional advisor, before acting on any information.
5. Referrals. I understand that Coach may recommend that I seek other types of treatment from other health professionals who are not affiliated with Coach. I understand that Coach may recommend that I seek other types of advice from other financial professionals who
are not affiliated with Coach. I understand that Coach does not supervise these professionals and is not responsible for them. I understand that they are not Coach’s employees and that they will bill separately for their services.
6. Assumption of Risk; Indemnity. I knowingly, voluntarily, and intelligently decide to receive the services described above, and I knowingly, voluntarily, and intelligently assume all risks involved in the same. As a result of my assumption of these risks, I agree to release, hold harmless, indemnify, and defend Coach from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the treatments or services described above, or arising out of or in connection with referral to other practitioners, merchants, or financial professionals for delivery of any services. As a result, I agree not to pursue a claim against any of the foregoing, if I am dissatisfied with the results of the above services.
7. Video-Coaching. Video coaching involves the use of audio-visual or other electronic communications to interact with you with respect to the services herein. The benefit is
speed of communication and access without physical travel; risks include inadequate communication due to the lack of physical presence. Additionally, in rare circumstances, security protocols could fail causing a breach of privacy. The alternative is an in-person face to face visit.
8. Group-Sessions. Coach provides the option and opportunity to participate in group sessions. These sessions are beneficial because they use a group session format that allows participants to discuss their own journeys and allow others to benefit from hearing from others and hearing coaching advice given to those participants. I UNDERSTAND AND CONSENT TO ALL OF COACH’S GROUP SESSIONS BEING RECORDED AND POSTED TO COACH’S PORTAL. If I do not want to be recorded then I acknowledge and understand I may choose to either not participate in the group sessions, or I may attend a group session by listening only and choosing to turn my audio and video off, and I may choose to submit questions anonymously. Coach will post all recordings to the client portal and will attempt to keep most, if not all, recordings password protected, however, Coach will not guarantee or warrant that all recordings will be password protected.
9. Private Health Information & HIPAA Compliance. I understand and acknowledge that as a physician I have an obligation under state and/or federal law, including HIPAA, to use appropriate safeguards to ensure patient information and medical information is protected from unauthorized use or disclosure. I understand that it is my duty and obligation to only refer to de-identified patient data when discussing particulars of a situation in my sessions
or group-sessions of health coaching.
10. Arbitration. Any dispute, claim, or controversy arising out of or relating to this Agreement or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this agreement to arbitrate, shall be determined by arbitration in Portland, Oregon, before one (1) arbitrator. The arbitration shall be administered by Arbitration Services of Portland and the hearing shall take place in Portland, Oregon. Judgment on the award may be entered in any court having jurisdiction. This provision shall not preclude either party from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. The arbitrator may, in the award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator. Each party has read and understood this Section (Arbitration) and understands that it thereby agrees to submit any claims arising out of this Agreement to binding arbitration, and that this dispute resolution provision constitutes a waiver of the Party’s right to a jury trial. EACH PARTY HAS READ AND UNDERSTANDS THIS SECTION and UNDERSTANDS THAT BY SIGNING THIS AGREEMENT, THE PARTY AGREES TO SUBMIT ANY CLAIMS ARISING OUT OF, RELATING TO, OR IN CONNECTION WITH THIS AGREEMENT, OR THE INTERPRETATION, VALIDITY, CONSTRUCTION, PERFORMANCE, BREACH, OR TERMINATION THEREOF TO ARBITRATION, AND THAT THE DISPUTE RESOLUTION PROVISIONS SET FORTH IN THIS SECTION CONSTITUTE A WAIVER OF THE PARTY’S RIGHT TO A JURY TRIAL.
NOTE: DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND FEEL THAT YOU UNDERSTAND IT. ASK ANY QUESTIONS YOU MIGHT HAVE BEFORE SIGNING THIS FORM. DO NOT SIGN THIS FORM IF YOU HAVE TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR MENTAL ABILITIES OR IF YOU FEEL RUSHED OR UNDER PRESSURE.
I have carefully read this form and acknowledge that I understand it. I have had opportunities to ask questions and accept and agree to all of the terms above. No representations, statements, or inducements, oral or written, apart from the foregoing written statement, have been made. If any portion of this form is held invalid, the rest of the document will continue in full force and effect.
SIGNATURE: ____________________________________________________________
NAME: ____________________________________________________________
DATE: ____________________________________________________________
Coaching Services Agreement
This Services Agreement is between you, the undersigned (“Client” or “You”) and Physician Coaching with Anne, LLC, an Oregon limited liability Coach, and its employees and agents (collectively, “Coach”). It is effective the later of the date of Client’s signature affixed hereto or the date Coach receives and accepts payment from the Client.
1. Services
Coach will provide professional coaching services to Client with the goal of helping Client to achieve better professional results and satisfaction. Coach will provide educational content and individual and group coaching sessions or meetings conducted by telephone or via video-conferencing technology.
2. No Medical, Mental Health, or Professional Services of Any Kind
Coach’s services hereunder will not include any kind of medical care, diagnosis, or treatment, mental health care (e.g., psychological care), diagnosis, or treatment, financial advice, or legal advice. Coach does not and will not provide emergency or urgent care. Coach may from time to time suggest Client may seek licensed medical or mental health care but does not and will not pay for, coordinate, refer, or oversee any such care.
3. Fees & Billing
Fees & Billing
Coach’s fees for services rendered hereunder are as follows:
$__________ per 50-minute session for __________ weekly / bi-weekly / monthly sessions.
$__________ for __________ weeks of group coaching plus up to __________ individual 50-minute one-on one coaching sessions
Client shall pay the total fee up front before any services are provided hereunder. Coach’s fees are non-refundable. If Client cancels participation for any reason, Client will receive no refund. Coach’s fees are earned upon receipt and shall not be segregated or otherwise held as a deposit.
4. Declination; Termination
Coach may decline services, if, in its sole discretion, Coach determines that the individual should be referred for medical or psychological or other care from a licensed healthcare practitioner. Further, Service may be terminated by Coach at any time, at the sole discretion of Coach, for nonpayment of fees, abusive or disruptive conduct, harassment, or if Coach determines that this program may not be a good fit for Client or Coach.
5. Not Medical or Mental Health Care
You understand, acknowledge, and agree that neither Coach nor any Coach personnel are providing primary or medical care.
6. Confidentiality. Client will not disclose or reveal other participant’s information or any confidential information disclosed by other participant(s) of the Program. As used in this Agreement, “Confidential Information” shall be defined as oral, written and/or recorded information concerning other participants, including but not limited to, the participant’s identification, personal or professional experiences, health information, and other private information. You agree that you will only use participant’s Confidential Information in good faith and for purposes of the Program. You agree that you will not disclose participant’s Confidential Information in any manner whatsoever or use it for any purpose other than the Program. Any unauthorized disclosure or misappropriation of another participant’s Confidential Information in violation of this Agreement may cause Coach and the other participant irreparable harm, the amount of which may be difficult to ascertain, and therefore you agree that Coach or the participant shall have the right to apply to a court of competent jurisdiction for an order enjoining any such further misappropriation and for such other relief as Coach or participant deems appropriate. This right is to be in addition to the remedies otherwise available to Coach or the participant. You also agree to indemnify Coach against any and all losses, damages, claims or expenses incurred or suffered by Coach as a result of your breach of this Agreement. If you are required by applicable law or regulation or by legal process to make any disclosure otherwise prohibited hereunder, you agree to provide Coach with prompt notice of such requirement prior to disclosure so that Coach may seek a protective order or other appropriate remedy. If a protective order or other remedy is not obtained, you agree to furnish only that portion of the Confidential Information which counsel advises is legally compelled to disclose.
7. Disclaimer of Warranties; Limitation of Liability. Coach disclaims all warranties, both express and implied, including any warranty of non-infringement, fitness for a particular purpose or merchantability; and Coach’s liability hereunder shall be limited to the aggregate fees paid to Coach by you for the Program until termination. Coach has no liability to you for any incidental and consequential damages, whether or not foreseeable or contemplated by Coach (including but not limited to any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Client, whether from technical failures or otherwise).
8. Disclaimer of Guarantee. Client accepts and agrees that he or she is 100% responsible for progress and results from the services provided hereunder. Coach makes no representations or guarantees verbally or in writing regarding performance of this Agreement other than those specifically enumerated herein. Although Coach aims to enhance overall wellness which can lead to good outcomes, Coach makes no guarantee or warranty that the Program will meet your requirements or that all participants will achieve the same results, or any particular result.
9. Indemnification. Client will defend, indemnify, and hold harmless Coach, Coach’s shareholders, trustees, affiliates, and successors from and against any and all liabilities and expense whatsoever— including without limitation, claims, damages, judgments, awards, settlements, investigations, costs, attorney’s fees, and disbursements—which any of them may incur or become obligated to pay arising out of or resulting from the offering for sale, the sale, and/or use of services or products or services under this Agreement; excluding, however, any such expenses and liabilities which may result from a breach of this Agreement or sole negligence or willful misconduct by Coach, or any of its shareholders, trustees, affiliates or successors.
10. Intellectual Property. Coach’s copyrighted and original materials will be provided to Client for individual use only and a single-user license. Client is not authorized to use any of Coach’s intellectual property for your business purposes. Client is not authorized to share, copy, distribute, or otherwise disseminate any materials received from Coach electronically or otherwise without the prior written consent of Coach. All intellectual property, including Coach’s copyrighted course materials, shall remain the sole property of Coach. No license to sell or distribute Coach’s materials is granted or implied.
11. Governing Law. This Agreement and any disputes arising out of this Agreement shall be governed by Oregon law without regard to conflict or choice of law provisions.
12. Entire Agreement. This Agreement, which incorporates the Disclosure, Release, and Waiver of Liability executed by Client, constitutes the complete and entire agreement between Coach and Client. There are no promises or representations except as set forth herein. No amendment shall be effective unless made in writing and signed by all parties.
13. Arbitration. Any dispute, claim, or controversy arising out of or relating to this Agreement or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this agreement to arbitrate, shall be determined by arbitration in Portland, Oregon, before one (1) arbitrator. The arbitration shall be administered by Arbitration Services of Portland and the hearing shall take place in Portland, Oregon. Judgment on the award may be entered in any court having jurisdiction. This provision shall not preclude either party from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. The arbitrator may, in the award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator. Each party has read and understood this Section (Arbitration) and understands that it thereby agrees to submit any claims arising out of this Agreement to binding arbitration, and that this dispute resolution provision constitutes a waiver of the Party’s right to a jury trial. EACH PARTY HAS READ AND UNDERSTANDS THIS SECTION and UNDERSTANDS THAT BY SIGNING THIS AGREEMENT, THE PARTY AGREES TO SUBMIT ANY CLAIMS ARISING OUT OF, RELATING TO, OR IN CONNECTION WITH THIS AGREEMENT, OR THE INTERPRETATION, VALIDITY, CONSTRUCTION, PERFORMANCE, BREACH, OR TERMINATION THEREOF TO ARBITRATION, AND THAT THE DISPUTE RESOLUTION PROVISIONS SET FORTH IN THIS SECTION CONSTITUTE A WAIVER OF THE PARTY’S RIGHT TO A JURY TRIAL.
NOTE: DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT AND FEEL THAT YOU UNDERSTAND IT. ASK ANY QUESTIONS YOU MIGHT HAVE BEFORE SIGNING THIS FORM. DO NOT SIGN THIS FORM IF YOU HAVE TAKEN MEDICATIONS WHICH MAY IMPAIR YOUR MENTAL ABILITIES OR IF YOU FEEL RUSHED OR UNDER PRESSURE.
I have carefully read this form and acknowledge that I understand it. I have had opportunities to ask questions and accept and agree to all of the terms above. No representations, statements, or inducements, oral or written, apart from the foregoing written statement, have been made. If any portion of this form is held invalid, the rest of the document will continue in full force and effect.
SIGNATURE: ____________________________________________________________
NAME: ____________________________________________________________
DATE: ____________________________________________________________
Please feel free to reach out to me at any of these links if you have any additional questions or concerns that were not addressed here.
Email: amhirsch@physiciancoachingwithanne.com
Phone: 503-567-9443
Phone: 503-567-9443
Google Phone: 503-567-9443
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