Executive Coaching Agreement

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This form is only for MCP executive coaching clients. If you are interested in executive coaching, please call 615-212-9207.

If you have not been to Music City Psych for a session in the last 3 years, or at all, please fill out this form and acknowledge your receipt of all notices here within.

We look forward to helping you reach for your goals.

New Executive Coaching Intake Form & Agreement

First Name(Required)

Last Name(Required)

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Client Full Name

Email(Required)

Phone(Required)

Address Line 1(Required)

Address Line 2

City(Required)

State(Required)

Postal Code(Required)

Date of Birth(Required)

Sex(Required)

Company Name(Required)

Title/Position(Required)

Industry(Required)

Emergency Contact First Name(Required)

Emergency Contact Last Name(Required)

Emergency Contact Phone(Required)

Emergency Contact Relationship(Required)

Referred By / Internet Site(Required)

Date of First Appointment(Required)

DISCLOSURES & AGREEMENTS We welcome you as a client and appreciate the opportunity to provide you with professional services. We hope that the following information will answer your questions regarding billing procedures.

E-Sign ACKNOWLEDGEMENT AND AGREEMENT: You agree that your signature for this electronic document is valid and will be enforceable as and to the full extent of a hand-written signature as an original for this entire Executive Coaching Agreement, including all sections and checkboxes here within. BY TYPING YOUR FULL NAME BELOW, you agree to this E-Sign Acknowledgement and Agreement.

First Name(Required)

Last Name(Required)

CONSENT: By writing your name below, you e-sign and agree that all information is yours, true and accurate. You also e-sign and agree to all acknowledgements and agreements within this document (Executive Coaching Agreement). Lastly, you e-sign and consent to services as discussed with your executive coach, including session fees.

Consent First Name(Required)

Consent Last Name(Required)

CREDIT CARD AUTHORIZATION FORM

First Name on Card(Required)

Last Name on Card(Required)

Billing Address 1(Required)

Billing Address 2

Billing City(Required)

Billing State(Required)

Billing Zip Code(Required)

Billing Phone(Required)

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Billing Country

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

*An authorization transaction may be created and then voided when first added to our system.

Preferred Payment Method(Required)

*Please note that David Pearl, LCSW does not currently accept credit cards at the time of the appointment, but does keep one on file for any late payments.

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