Client/Practitioner Agreement

  • Request
  • Ethical
  • Scope
  • Names
  • Conditions

Please complete this form together

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

I have confirmed our booking by making payment by internet banking.

Confidentiality (Keeping things private)

The Relationships Practitioner aspires to ensure the service you you receive is confidential within the limits of the NZAC Code of Ethics and the Aotearoa New Zealand Privacy Act 1993. I consent to this.

The Relationships Practitioner agrees not to disclose to any other person any information received as part of the confidential couple coaching relationship without your express consent. Circumstances under which The Practitioner would share information would be where your interests or other's interests, or the law require disclosure. One such situation would be the risk to health/life of the clients/others. I consent to this.

Scope of Practice

I have read the Scope of Practice, at , and I consent to the scope of practice provided by The Practitioner including their specific focus on relationships between couples.

I have read 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 48 hours notice when rescheduling or cancelling appointments. Bookings changed within the notice period will incur a fee of 1/2 the session rate. All non-attendance will incur the full fee and you will be invoiced. Thank you for respecting these conditions when booking your appointment.

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