Confidentiality &
Release of Information Form



Directions:
Fill out all sections of this form. Click submit when completed. A copy of the contents will be sent to the coach as well as to your provided e-mail.
All fields in this form are compulsory.

Basic details:


Your Full Name: Email Address:
Phone Number: Home Address:
Release of Information:

  • I understand that Jennifer will not share information about our sessions without my permission.
    (Check the box of either A or B below.)


  • I understand Jennifer Kumar respects and upholds confidentiality. She will only release information about our work to others with my written permission, court order or legal subpoena.
  • Confidentiality Online: Though both the client and the coach will be careful about e-mail and phone communication, we both understand these methods of communications are not 100% secure. We will both take care not to share confidential messages with care and caution.
Agreement and Confirmation
I, as the client, attest I have read, understood and checked the items on this list myself. I attest that if I had any questions about the items in the lists above, I would have discussed them with Jennifer Kumar before I signed this form.

By filling out this form and submitting it digitally, it acts as an agreement between you and I that we will work together to the best of our abilities to achieve your goals.

This form is being submitted by:
(Name, as provided in Basic Details)
On the date of:




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