Client Disclosure Statement
for the Private Practice of
Michelle Chalfant MS CHC MHt LPC-NC
Masters Degree Rehab Counseling 1995 Medical College of Virginia
Licensed Professional Counselor (North Carolina License)
Certified Holistic Life CoachRadiant Health Institute
Ordained Minister-School of Healing Arts
Master Transpersonal Hypnotherapist
Advanced Psych-K practitioner
NLPNeuro Linguistic Programming
PIT Post Induction Therapy
EFTEmotional Freedom Technique
The primary populations served are individuals and couples with an emphasis on relationships, communication issues and life transitions (marriage, divorce, grief, new job, empty nest etc.) as well as trauma, codependency, depression and anxiety. My approach is eclectic and offers a blend of therapy and life coaching. Added to this are a variety of techniques that illicit change and create emotional balance and empowerment.
Fees for individual and couples counseling are $195 for 55 minutes. When needing to cancel a 24-hour notice is required or half of the session fee is due. Cash, check and credit cards are acceptable forms of payment.
Your session is always held in confidence. Professional Ethics and Tennessee State Law indicate that confidential information is controlled by the client. This means that, as a general rule, information shared in sessions with a counselor will be held in confidence. There are two exceptions to this general rule. In the case of an emergency where I believe a client is at risk of hurting him/herself or another person, there may be a breach in confidentiality. Tennessee law requires that child and elderly abuse in any form be reported to the Department of Human Services.
Benefits and Risks of Counseling/Coaching
When we consider making changes in our lives, this typically involves the modification of emotions, attitudes and behaviors. When we do this, we may notice a shift in our empowerment, sense of self, self esteem, etc. and relationships may change. We may even notice our symptoms getting worse before getting better. We as therapists/coaches cannot guarantee a specific outcome; clients are ultimately responsible for their own growth.
As your therapist/coach there may be suggestions to see other practitioners such as a massage therapist, chiropractor, nutritionist, energy healer, acupuncturist, psychiatrist or another practitioner to compliment our sessions. These are simply suggestions and not obligatory, it is ultimately up to you to decide to go or not.
If at any time you are in crisis and unable to reach me in an emergency, please contact the Crisis Help Line at 615-244-7444 or by going to your local emergency room.
If you feel the need to file a complaint, please contact NC Board of LPC’s.
P.O. Box 77819 Greensboro, NC 27417 • (844) 622-3572
My license number is: 2985
I have read and understand the nature of these sessions and freely elect to receive sessions from Michelle Chalfant. I, the client, release Michelle Chalfant from any and all claims of malpractice, nondisclosure, or lack of informed consent. I, the client, freely assume any and all risks of these sessions.
Release and Waiver of Liability and Indemnity Agreement
In consideration of being permitted to participate in Life Coaching offered by the coach indicated below, the undersigned participant named below agrees:
There are social and emotional risks in participating in the above mentioned activity. I fully understand and acknowledge that there may be risks not known to us or are not reasonably foreseeable to us at this time.
I accept and assume such risks and responsibilities for the losses and/or damages following such psychological or physical injury, disability, paralysis or death, however caused and whether caused in whole or in part by the negligence of the Release(s) named below.
The UNDERSIGNED further expressly agrees that the foregoing release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the law of the Province or State in which the coach is conducting events and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
If, despite signing this release, the undersigned participant makes a claim against any of the Releases, the undersigned participant will reimburse the Release(s) for any money which they have paid to the participant, or on his/her behalf, and hold them harmless.
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY, INCLUDING ANY NEGLIGENCE OF THE COACH NAMED BELOW TO THE GREATEST EXTENT ALLOWED BY LAW. I have saved a copy of this document if desired.
Name of Holistic Life Coach: Michelle Chalfant
The parties agree that the electronic signature of a party to this Agreement shall be as valid as an original signature of such party and shall be effective to bind such party to this Agreement. The parties agree that any electronically signed document (including this Agreement) shall be deemed (i) to be "written" or "in writing," (ii) to have been signed and (iii) to constitute a record established and maintained in the ordinary course of business and an original written record when printed from electronic files. Such paper copies or "printouts," if introduced as evidence in any judicial, arbitral, mediation or administrative proceeding, will be admissible as between the parties to the same extent and under the same conditions as other original business records created and maintained in documentary form. Neither party shall contest the admissibility of true and accurate copies of electronically signed documents on the basis of the best evidence rule or as not satisfying the business records exception to the hearsay rule. For purposes hereof, "electronic signature" means a manually-signed original signature that is then transmitted by electronic means; "transmitted by electronic means" means sent in the form of a facsimile or sent via the internet as a "pdf" (portable document format) or other replicating image attached to an e-mail message; and, "electronically signed document" means a document transmitted by electronic means and containing, or to which there is affixed, an electronic signature.