Parent #1 Name

First Name

Last Name

Parent #2 Name

First Name

Last Name

Best Phone Number to call for follow-up calls *

(###)

###

####

Child's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Our work together *

Please check the boxes next to each statement to signify your acknowledgement of the details of our work together. These items are required before we begin working together.

I acknowledge I will forfeit my time if I am more than 20 minutes late to my consultation call without communicating via email (katie@behavioristnextdoor.com)

I acknowledge my payment is non-refundable unless otherwise specified via email or form.

I acknowledge I will keep a sleep log, be on time for all follow-up calls, and communicate as needed throughout the coaching process.

I acknowledge sleep coaching advice is NOT medical advice. You are solely responsible for discussing any possible medical conditions with your child’s physician or other health professional. You understand that you assume primary responsibility for the health of your child and, to the extent permitted by law, you will not hold me or my practice responsible for any outcomes resulting from complications that are outside of my control.

I acknowledge that the Behaviorist Next Door (BND) does not accept insurance. I may submit my invoices to my insurance company but BND cannot guarantee reimbursement for fees or for expenses I may incur for the coaching sessions.

This form reflects the entire understanding between us and may only be changed in writing signed by both of us. If a court decides any of the terms are unenforceable, we agree that these terms will be severable from the agreement and all other terms of our agreement will remain in effect. By checking all of these boxes, I acknowledge that I understand and agree with all of the information herein.