Client Form – Online Agreement

Please fill out the form below with your information, in agreement with the following:

By filling out this form, I acknowledge that it is my will to enter a relationship with Yol Swan to receive healing and/or guidance and/or coaching in different areas, for my self-growth and/or business. I understand that she is not attempting to or engaging in the practice of psychotherapy or medicine without a license, nor is she holding herself to be a psychologist, psychiatrist, psychological therapist, licensed therapist or counselor, social worker, or any other medical or health professional.

I agree that Yol Swan does not claim to “diagnose, mitigate, treat, cure, or prevent disease” or symptoms as defined by the FDA and/or the State of North Carolina, and that the conversion to any specific religion, belief, or philosophy is not required by Yol Swan for me to participate in any type of session with her.

I understand that she encourages me to seek out the care of a licensed physician, therapist, or other health care provider if I become aware of or suspect that I have any form of medical, psychological or emotional distress, concern, symptom, indication of disease of any sort, or any other health related problem.

I agree to pay Yol Swan’s fees in full before any scheduled appointments. I understand that she has a 24-hour cancellation policy and that said fees will not be refunded if I do not change or cancel my appointment at least 24 hours in advance during business hours or if I fail to reschedule appointments of a prepaid program within 2 weeks of their original date. If discounts were applied to my program(s), refunds may be made after deducting any sessions/services received at the full current baseline rate, not a discounted rate for weekly programs (the baseline rate is the rate per session at the current lowest level of a monthly program). To see current baseline fees for spiritual counseling/coaching click here and for conscious business coaching click here.

I also agree to be added to Yol’s client mailing list to receive newsletters and notices. I understand my information won’t be shared with anyone and I can unsubscribe at any time from this and any other list to which I may have subscribed.

    Full Name

    Date of Birth (in this format: Month/Day/Year)

    Address

    City, State/Province

    Country, Zip (postal code)

    Home Phone

    Cell Phone

    Email Address

    Skype username

    Occupation

    How did you hear about me/Referred by?

    Are you taking any medication? If yes, please explain

    Do you agree with all business policies stated on this page?
    Yes, I agree with all your business policies

    You must agree with my Privacy Policy before submitting this form.
    Yes, I have read and agree with your Privacy Policy