Intake Form

Relationship improvement

Emotional regulation

Trauma recovery

Communication skills

Personal growth

Other

Coaching vs Therapy Agreement: I understand that The Realignment Collective is a coaching program, not psychotherapy. Although Allison Burgess is a Licensed Professional Counselor (LPC), she is not acting as my therapist in this program. Coaching does not diagnose or treat mental health disorders and is not a substitute for therapy or medical care. I agree

Responsibility and Risk: I understand that personal growth may involve emotional discomfort and I am responsible for my own decisions, actions, and outcomes. I agree

Crisis Disclaimer: This program does not provide crisis support. If I am in crisis, I will contact 911 or 988. I agree.

Confidentiality: I understand coaching is not HIPAA protected and group settings are not confidential environments. I agree.

Payment Policy: All payments are final unless otherwise stated. No refunds once content is accessed. I agree.

GROUP COACHING CLAUSE: Group Coaching Acknowledgment I understand that group coaching involves sharing in a group setting. I agree to respect the privacy of other participants; however, I understand that confidentiality cannot be guaranteed in a group environment. I accept full responsibility for what I choose to share. I accept.

COUPLES / RELATIONSHIP DISCLAIMER (VERY IMPORTANT): Relationship Coaching Disclaimer I understand that relationship or couples coaching is not therapy and does not involve mediation, arbitration, or clinical intervention. The coach does not determine right or wrong, nor ensure relationship outcomes. I understand that participation may bring up conflict or emotional discomfort, and I accept full responsibility for my actions and reactions within my relationship. I agree and consent.

LPC ROLE CLARIFICATION: Professional Role Clarification I understand that although Allison Burgess is a Licensed Professional Counselor (LPC), she is acting solely in the role of a coach within this program. No therapeutic relationship is being established. Participation in this program does not create a client-therapist relationship. I agree.

MANDATORY REPORTING & SAFETY CLAUSE: Safety & Legal Exceptions While this is a coaching relationship, I understand that if I disclose intent to harm myself or others, abuse of a minor, elder, or vulnerable person, or other situations required by law, appropriate authorities may be contacted. I agree

JURISDICTION / LOCATION CLAUSE: Jurisdiction I understand that coaching services are provided under the laws of the State of Georgia. Any disputes arising from this agreement will be governed by Georgia law. I AGREE.

NO GUARANTEES + RESULTS DISCLAIMER: No Guarantees I understand that results from coaching are not guaranteed and depend on my participation, effort, and personal circumstances. I agree.

Communication & Boundaries I understand that: Coaching communication is limited to business hours Responses are not immediate or guaranteed This is not a crisis communication channel . I agree.

Intellectual Property I understand that all materials provided are: Owned by The Realignment Collective For personal use only Not to be shared, copied, or distributed . I agree

VOLUNTARY PARTICIPATION: Voluntary Participation I acknowledge that I am voluntarily participating in coaching services and may discontinue at any time. I AGREE.

Jurisdiction I understand that coaching services are governed by the laws of the State of Georgia. I agree

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