Consent for Treatment
Confidentiality | Consent | Disclaimer
Please print a copy of this page for your personal records.
- I understand that REFUSETOQUIT.com and it agents are providing professional counseling and life coaching services via internet (online), e-mail, telephone, and in-person.
- I understand that it is my responsibility to secure the appropriate services during situations that are an emergency such as, suicidal attempts or ideation, domestic abuse, emotional and physical abuse, fire, and all other emergencies. I must call 911, fire department, police, suicide hotline, psychiatric hospital.
- I understand that REFUSETOQUIT.com does not accept health insurance for payment of services at this time. All services rendered must be paid prior to service delivery by way of internet (on-line chat and e-mail), telephone, or in-person.
- I authorize treatment and voluntarily consent to all advice, counseling, suggestions, evaluation or treatment received by internet on-line chat and e-mail), telephone, or in-person. In addition, I hereby agree that REFUSETOQUIT.com and its agents do not guarantee any results. Lastly I understand that for any treatment to be effective, I must be consistent, have a high motivation to change my (you, the client, utilizing REFUSETOQUIT.com) circumstances, and following through with recommendations and interventions given.
- I understand that all REFUSETOQUIT.com services are directed and supervised by James E. Coston and administered by James E. Coston III and/or the assigned therapist/life coach at the Refuse To Quit, LLC headquarters in Philadelphia, PA or at an Refuse To Quit, LLC approved satellite office in the United States.
- I understand that REFUSETOQUIT.com may refuse or terminate services at the sole discretion of James E. Coston III, Founder and CEO of RREFUSETOQUIT.com, and its parent company Refuse To Quit, LLC.
I have been advised to read and re-read this document very carefully and agree to release REFUSETOQUIT.com, its agents, and James E. Coston III of all liability. This release, waiver and disclaimer applies to all demands, misunderstanding, liabilities, implied, not implied, or suggestive notions on my part or on the part of REFUSETOQUIT.com. This waiver additionally includes any claim, liability, demands that may arise out of personal injury, theft, homicide, suicide, threats, emotional abuse or damages, or victimization by a third party due to counsel given by REFUSETOQUIT.com through the internet (online), e-mail, or telephone, and use of this website. I agree to hold harmless and release REFUSETOQUIT.com, its agents, and James E. Coston III of all liability, responsibility, and damages forever.
REFUSE TO QUIT AND LIFE SURRENDERS!™
