LONGETIVITY LIFESTYLES LLC
Life Coaching & Wellness Consulting – Informed Consent and Privacy Agreement

1. Client Information

Name: __________________________________________
Date of Birth: ___________________________________
Phone: _________________________________________
Email: __________________________________________
Address: ________________________________________
Emergency Contact (Name & Phone): _______________________________

2. Nature of Services

Longevity Lifestyles LLC provides holistic life coaching, wellness guidance, lifestyle education, and goal-support services. These services may include:

• Habit and behavior change coaching

• Accountability and motivational support

• Nutrition and lifestyle education (non-medical)

• Stress management and mindset development

• Personal development strategies

• Holistic wellness recommendations

Life coaching is not medical care, mental health therapy, or a substitute for licensed healthcare.

The coach does NOT:

• Diagnose illness or disease

• Prescribe medication

• Provide psychotherapy

• Provide medical treatment

• Treat mental health disorders

Clients should consult a licensed physician or qualified healthcare professional for any medical concerns.

3. Client Responsibility Agreement

By signing, you acknowledge:

• You are responsible for your own decisions, actions, and results.

• You will seek medical advice before making major dietary or lifestyle changes.

• You understand results vary based on effort, consistency, and individual biology.

• You may stop coaching at any time.

4. Risks & Benefits

Possible Benefits

• Improved habits and discipline

• Increased awareness and clarity

• Better wellness routines

• Motivation and accountability

Possible Risks

• Emotional discomfort during personal growth

• Temporary fatigue or adjustment when changing habits

• Frustration when building new behaviors

You voluntarily accept these risks.

5. Confidentiality

Longevity Lifestyles LLC respects your privacy.

All personal information shared during coaching sessions will remain confidential except when:

1. Required by law

2. There is risk of harm to yourself or others

3. You provide written permission

6. Privacy & Data Protection Consent

By signing this agreement, you consent to:

• Storage of your contact and session information in secure records

• Communication via phone, text, email, or video platforms

• Use of anonymized data for internal program improvement

Your information will never be sold or shared with third parties for marketing.

You may request deletion of your data at any time in writing.

7. Communication Consent

Please check preferred communication methods:

[ ] Phone Call
[ ] Text Message
[ ] Email
[ ] Video Call (Zoom/Online Platform)

You understand electronic communication carries some privacy risks.

8. Cancellation & Scheduling Policy

• 24-hour notice required for cancellations or rescheduling

• Missed sessions without notice may be forfeited

• Packages expire after ______ months unless otherwise agreed

9. Payment & Refund Policy

All coaching services are educational and time-based.

• Payments are due before sessions unless arranged otherwise

• No refunds for completed sessions

• Prepaid packages are non-refundable but transferable at discretion

10. Liability Waiver

You agree to release Longevity Lifestyles LLC, its coaches, and affiliates from liability related to:

• Lifestyle or habit changes

• Nutrition adjustments

• Fitness recommendations

• Personal decisions made during or after coaching

You accept full responsibility for your health choices.

11. Voluntary Consent

I confirm:

• I have read and understood this agreement

• I had the opportunity to ask questions

• I voluntarily agree to participate in coaching services

Client Name (Print): ______________________________________

Client Signature: _________________________________________ Date: ___________

Coach Name: ______________________________________________

Coach Signature: _________________________________________ Date: ___________

Longevity Lifestyles LLC
Client copy provided upon signing