Congratulations on your decision to participate in the Milestone Mind program!

With the help of your coach, you will gain deeper insight into who you are, what truly drives and motivates, and where to confidently and without hesitation put your focus behind.

We believe in the Process First, Outcome Second approach, where meeting consistently is vital to the success of this program. We believe that the journey is where your deepest wisdom is gained, and to hasten that would only leave you confused and more frustrated. 

We are 100% committed to your success, however it is with your 100% commitment that lasting and meaningful results will come of this program. 

The Milestone system lasts 5-months At the end of the 5 Milestones, we will review progress to date, and determine if continuing to deepen your knowledge of yourself is desired. This will be a verbal agreement, where would then amend this contract to continue until the next 5 Milestones are compete, and then so on from there. 

You accept full responsibility of your own health and well-being AND you acknowledge that no responsibility is assumed by the leaders of this program.

 

Milestone Mind Terms and Conditions

  1. Clients are to be billed and charged monthly or as one-time payment at the agreed upon rate agreed to at time of purchase unless there is a 14-day notification prior to the next billing cycle.
  2. Clients arrive late will receive the remaining scheduled session time, unless other arrangements have been made with the coach.
  3. No Milestone Mind refunds will be issued for any reason, including but not limited to relocation, illness, unused sessions, classes or monthly packages.

 

Disclaimer: Life Coaching, Neurolinguistic Programming (NLP), Hypnosis and other modalities used provide impressive results for most people but there is no guarantee it will achieve your goals or be as beneficial as it is for most people. Please consult your own physician and/or therapist regarding your participation.

I have requested services with Milestone Mind and/or David Nelson, Life Coach and Certified Practitioner of NLP. I understand that David Nelson is not a licensed medical doctor or therapist. This consultation is not meant to diagnose or treat any disease, but rather it is intended to provide information that will promote the conditions under which natural healing skills and abilities are strengthened. It is designed to give insights into innate healing potential and guide toward a more healthy and balanced lifestyle. I also realize that the sessions are for increasing coping skills, teaching how to manage stress in creative, healthy ways and to help eliminate unhealthy habits.

I certify that my participation is of my own free will and I accept complete responsibility for my well-being at all times. I further certify that I am a healthy individual and that I am physically and psychologically fit to fully participate, and I know of no reason, nor have I been informed by my physician or psychologist of any reason, why my participation would do me harm of any nature. I agree to release and hold harmless David Nelson and Milestone Mind from any claim arising out of any portion of these sessions in which I am voluntarily participating, including any claim for physical and/or mental injury to myself, whether caused by negligence or otherwise. I also understand that although these sessions may raise emotional issues, they are not intended to provide a therapeutic environment or be a substitute for ongoing counseling or psychotherapy. Resolution of any issues which may surface and which may warrant counseling will be my sole responsibility and will be undertaken at my sole discretion and at my own expense. I am clear that I am not being treated for specific medical problems.

I clearly understand that all services rendered to me are to be paid in full at the time of each session.

For further sessions I shall give David Nelson and Milestone Mind a minimum of 24 hours notice in the event of a cancellation. I understand if I fail to comply, I will be responsible for paying the amount of service scheduled. I also take responsibility for being on time for my appointment, and will be charged for the full scheduled appointment time.

Coaching and NLP sessions are kept strictly confidential between the client and practitioner. 

I have read all the above paragraphs and understand and accept the policies as stated, as well as acknowledge Notice of Privacy Practices. 

 

RELEASE STATEMENT

I Hereby authorize Milestone Mind, Inc. and or David Nelson, NLP Life Coach and Certified Master Practitioner of NLP to coach me for the purposes outlined in this Intake Interview Form, and for any other future purposes that I may request. I understand that the success of my coaching sessions depends greatly on my own ability and desire to affect change in myself. I understand that the results of my sessions depend greatly on my own serious participation, and that Milestone Mind cannot offer any guarantee of the success of our work together. I am aware, however, that Milestone Mind will do everything in their power to ensure my success. I also understand that I have other choices from which to seek assistance regarding my specific concerns, and I have chosen coaching with Milestone Mind, Inc. at this time.

 

Client Bill of Rights

© 2016

Contact Information: My name is David Nelson. I can be contacted through my office at
5 Hampden Dr., Easton, Ma or by telephone at 508-825-3186.

Education and Training: I hold a Bachelor of Arts degree from Lafayette College, an Executive Education Certificate from Harvard Business School, and am a Certified: NLP Practitioner, IAPLC and ICF NLP Master Practitioner, Certified Warrior Mind Mental Strength Coach, and NSCA Personal Trainer.

Notice: “THE STATE OF MASSACHUSETTS HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR THE PRACTICE OF HYPNOTISM, NLP, HANDWRITING ANALYSIS OR REIKI. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATIONAL PURPOSES ONLY. Under law those practicing Hypnotherapy, NLP, REIKI or Handwriting Analysis, may not provide a medical diagnosis or recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. In the event my services are terminated by a client, the client has a right to coordinated transfer of services to another practitioner. A client has a right to refuse my services at any time. A client has a right to be free of physical, verbal or sexual abuse. A client has a right to know the expected duration of treatment, and may assert any right without retaliation.” 

Redress: In any services I provide, I practice in accordance with each Association’s Code of Ethics and Standards. If you ever have a complaint about my services or behavior that I cannot resolve for you personally, you may contact the above Associations to which I belong to seek redress. Other services than my own may be available to you in the community. You may locate such providers in the telephone book.

Fees: The charge for my services are discussed and agreed upon prior to scheduling an appointment
You will be given 30 days notice of any change in fees. At this time, I do not take insurance. 

Confidentiality: I will not discuss or release any information to anyone without a written authorization from you, except as provided for by law. You have a right to be allowed access to my written record about you.

Insurance: I suggest you think of my services as something that you will pay for personally. That will both protect your privacy and help you value the work you are doing more. In general, insurance companies do not as of yet cover Hypnosis, NLP, REIKI or Handwriting Analysis services, and I caution you not to expect them to do so.

My Approach: My approach is educational and coaching in providing clients with options for self-help techniques that facilitate agreed upon enhancements or changes. I do not represent my services as any form of health care or psychotherapy, and despite research to the contrary, by law I may make no health benefit claims for my services. 

I have received and read this Client Bill of Rights and understand what I have read.