Service Agreement: Grief Coaching, Education & Support
Effective Date: ( upon appointment)
Coach/Facilitator: (” Provider”) Lisa Dembeck/Certified Grief Educator at Hudson Valley Grief Services
Client: [Full Name] ("Client" or "Participant")
1. Scope of Work Options
A. The Provider agrees to deliver the following services as part of the Hudson Valley Grief Services Programing and Sessions
B. Grief Coaching: $50 (1 individual coaching session + one follow up email) each lasting [Duration, e.g., 60 minutes], conducted via [Meets/In-person].
C. Grief Session Packages: conducted via [Meets/In-person].
Gentle Start package $120 (3 sessions + email support)
Steady Support Package $240 (6 sessions + email support)
D. In Person Support Groups monthly: As needed Paid per session$10 per session at a duration of 60-90 minutes
E. Support Group Services: As needed monthly group sessions facilitated by the Provider. Participants must adhere to group guidelines, including confidentiality and mutual respect.
F. Educational Materials: Access to [Workbooks, webinars, or resources] provided by the Provider for the duration of the engagement.
Nature of Service: Client acknowledges that these services are for coaching and educational purposes only and are not a substitute for clinical therapy, psychotherapy, or medical advice.
2. Payment Terms
Service Fee: The total fee for the program is listed above depending on which scope of work you choose.
Payment Schedule: Payment is due in full prior to the first session unless a monthly installment plan is otherwise agreed upon in writing. Sliding Scale fee available.
Method of Payment: Payments can be made via [Stripe, PayPal, Bank Transfer, Venmo or Zelle].
Late Fees: Payments delayed by more than 7 business days may result in a late fee of $[25] or a temporary suspension of services.
3. Cancellation & Rescheduling Policies
To maintain the integrity of the coaching schedule and group dynamics, the following policies apply:
Individual Session Rescheduling: A minimum of 24-hour notice is required to reschedule a session. Failure to provide notice will result in the session being forfeited without a refund.
Group Sessions: Because group seats are limited, there are no refunds or make-up sessions for missed group attendance. See Group Ground Rules below
No-Shows: If the Client is more than [Number, e.g., 10-15] minutes late to a scheduled session, the session is considered a "no-show" and the fee is forfeited by the client.
Client Termination: The Client may cancel the agreement at any time; however, no refunds will be issued for unused sessions once the program has commenced.
Provider Cancellation: If the Provider must cancel a session due to an emergency, the Client will be offered a rescheduling option or a pro-rated refund for that specific session.
4. Confidentiality & Liability
Privacy: All individual coaching discussions and group disclosures are strictly confidential.
Limitation of Liability: The Provider is not liable for any direct or indirect damage arising from the Client’s personal decisions or actions following the sessions.
Signatures:
___________________ (Provider) Date: _
_______________ (Client) Date: _

To foster a safe and supportive environment, all participants agree to the following guidelines:
Confidentiality: What is said in the group stays in the group. Do not share the names or personal stories of fellow participants outside of sessions.
No Advice-Giving: We are here to offer support, not solutions. Share your own experiences using "I" statements rather than telling others what they should do.
Respect for Diverse Grief: Recognize that every loss is unique. We respect all individual experiences, beliefs, and timelines for healing without judgment or comparison.
Shared Airtime: Be mindful of the time you spend speaking to ensure every participant can share.
Active & Mindful Listening: Focus on being present for others. Avoid interruptions, side conversations, or using electronic devices during sessions.
Right to Pass: Participation is encouraged, but you always have the right to remain silent or pass on a specific topic.
Emergency Mental Health Disclaimer*
Important: The Provider is a grief coach/educator and not a licensed mental health professional, therapist, or emergency responder.
Not a Crisis Service: Coaching services are not intended for individuals in active crisis or experiencing severe clinical depression or suicidal ideation.
Client Responsibility: You are solely responsible for your own mental and physical well-being. If you feel you are in danger of harming yourself or others, you must contact emergency services immediately.
Immediate Assistance Resources: If you are experiencing a mental health emergency, please use the following resources:
Emergency Services: Dial 911 (or your local emergency number).
988 Suicide & Crisis Lifeline: Call or text 988 (available 24/7 in the U.S. and Canada).
Crisis Text Line: Text HOME to 741741.
Mandatory Referral: If the Provider determines that your needs exceed the scope of coaching (e.g., risk of harm to self or others), they reserve the right to pause services and refer you to a licensed clinical professional.
Mandatory Reporting Policy
While the Provider maintains a high standard of client confidentiality, they are legally and ethically obligated to breach that confidentiality in specific circumstances where safety is at risk. By signing this agreement, the Client acknowledges that the Provider will report information to the appropriate authorities (such as law enforcement or social services) in the following situations:
Imminent Harm to Self: If the Client expresses a specific intent, plan, and means to harm themselves or commit suicide.
Threat of Harm to Others: If the Client makes a serious threat of physical violence against an identifiable person or entity.
Abuse or Neglect of Vulnerable Populations: If there is reasonable cause to suspect the abuse, neglect, or exploitation of a minor (under 18), an elderly person, or a dependent adult.
Court Orders: If the Provider is served with a legally valid subpoena or court order requiring the release of records or testimony.
Note for Group Services: In a group setting, if any participant discloses information that triggers these reporting requirements, the Provider is still obligated to report the incident, even if it disrupts the group dynamic.

Liability Waiver and Release of Claims
Service: Grief Coaching, Education, and Support Groups
Provider: Hudson Valley Grief Services
Participant:
1. Acknowledgment of Non-Clinical Services
I, the Participant, understand and acknowledge that Hudson Valley Grief Services provides coaching and educational services only. I clearly understand that the Provider is not a licensed psychologist, psychiatrist, therapist, or medical professional. I understand that grief coaching is not a substitute for medical diagnosis, prescription of medication, or clinical psychotherapy.
2. Assumption of Risk
I understand that grief coaching and support group participation may involve the discussion of sensitive, emotional, and potentially distressing topics related to loss. I voluntarily choose to participate in these services and assume all risks associated with the emotional nature of this work. I am responsible for my own emotional well-being and for seeking professional medical or clinical help if my needs exceed the scope of coaching.
3. Waiver and Release
To the maximum extent permitted by law, I, on behalf of myself, my heirs, and my representatives, hereby release, waive, and discharge Lisa Dembeck /Hudson Valley Grief Services, LLC., its employees, and facilitators from any and all liability, claims, or causes of action arising out of my participation in these services. This includes, but is not limited to, any personal injury, emotional distress, or financial loss that may occur during or after my engagement with the Provider.
4. Limitation of Liability
The Provider shall not be held liable for any direct, indirect, or consequential damage resulting from any decisions I make or actions I take based on the coaching or educational materials provided. All suggestions or tools offered by the Provider are for educational purposes, and the final responsibility for any action taken lies solely with me.
5. Indemnification
I agree to indemnify and hold harmless Hudson Valley Grief Services against any and all claims, suits, or actions of any kind brought against them for any liability or damage arising from my own conduct during coaching sessions or group meetings.
6. Emergency Consent
In the event of a medical or mental health emergency during a session, I authorize the Provider to contact my designated Emergency Contact or emergency services (911). I understand that any costs incurred for emergency services are my sole responsibility.
Participant Acknowledgment:
I have read this Liability Waiver and Release of Claims in its entirety. I understand that by signing this document, I am giving up certain legal rights. I sign it freely and voluntarily.
Participant Signature: ______________ Date: _

Emergency Contact Information**
To ensure your safety and provide the best support during our sessions, please provide the details of a person who can be reached in the event of a medical or mental health emergency.
Primary Emergency Contact
Full Name: _________________
Relationship to Participant:
Primary Phone Number:
Alternative Phone Number:
Secondary Contact (Optional)
Full Name: _
Primary Phone Number:
Participant Authorization
I authorize Lisa Dembeck/Hudson Valley Grief Services to contact the individual(s) listed above only in the event of an emergency where my safety or the safety of others may be at risk. I understand that it is my responsibility to update this information if it changes.
Signature: _ Date: _