Client/Practitioner Agreement

  • Request
  • Private
  • Scope
  • Name
  • Home

Please complete this form together

We/I have requested the relationship couple session(s).

Confidentiality (Keeping things private)

All we discuss is confidential. We consent to the a few exceptions as listed in the disclosure document at

Scope of Practice

I have read, and agree to, the Scope of Practice, at , and I consent to the scope of practice provided by The Practitioner.

I have read and understand the Disclosure Statement at and agree to this

Partner 1

First-Name & Last-Name



Partner 2

First-Name & Last-Name




Number & street




Rock Solid Relationships requires 24 hours notice when rescheduling or cancelling appointments. Cancellations, missing your appointment and rescheduling within 24 hours of the session time will incur a fee of 40% the session rate for the missed session. I support parents and children. If you (or children in your care) have sickness symptoms, or are self-isolating, then txt or phone Henk at least one hour before the session start time. You will not be charged if you txt or call up to one hour before the start time - if there is sickness. Do not come in sick. It is better to stay home. Perhaps you can meet via ZOOM instead. Or reschedule. Thank you for respecting these conditions when booking your appointment.

I understand and agree to conditions for rescheduling, cancelling and non-attendance.