WELLBEING & PERSONAL DEVELOPMENT AGREEMENT Maria Pellicano Communication & Voice Specialist - Counsellor | Professional Certified Coach (ICF) Meditation Teacher “Knowing thyself is the beginning of wisdom” AristotleCLIENT INFORMATIONName(Required) First Last Date of Birth(Required) DD slash MM slash YYYY OccupationAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile(Required)Email(Required) EMERGENCY CONTACTName(Required)Relationship(Required)Phone(Required)I consent to Maria contacting my nominated emergency contact if there is a serious concern for my immediate safety or wellbeing and I am unable to provide consent at the time. Yes No HEALTH INFORMATIONGP or Doctors NameCurrent Medications, if relevantIs there any physical or mental health information you would like me to be aware of?Welcome Thank you for choosing to work with me. This agreement outlines how we will work together and is designed to establish a safe, respectful and confidential environment where you can explore your wellbeing, personal growth, communication, relationships, leadership and life challenges. My approach is holistic, person-centred and collaborative, integrating counselling, coaching, mindfulness, communication development and practical strategies to support meaningful and lasting change.About Your Practitioner Maria Pellicano has over 25 years’ experience supporting individuals, professionals, business leaders and performers in developing greater wellbeing, confidence, resilience and effective communication. Maria’s work integrates evidence-informed counselling, coaching, mindful awareness, communication development and personal growth strategies tailored to each individual’s needs. Professional qualifications and memberships include: Diploma of Counselling Professional Certified Coach (PCC) – International Coaching Federation (ICF) Member – Australian Holistic Healers and Counsellors Association (AHHCA) Qualified Meditation Teacher Maria practises in accordance with recognised professional and ethical standards and is committed to ongoing professional development and best practice.Purpose of Our Work Together The purpose of our sessions is to support your overall wellbeing and personal development by helping you to: Develop greater self-awareness Improve emotional wellbeing and resilience Strengthen communication and relationships Navigate personal or professional challenges Build confidence and clarity Explore values, purpose and direction Develop practical strategies for positive and lasting change Every client is unique, and our work together will be tailored to your individual goals and circumstances.What has brought you to this service at this time?(Required)What would you most like to achieve through our work together?(Required)Areas You Would Like to Focus On(Required) Personal Wellbeing Emotional Wellbeing Stress Management Leadership Career or Business Life Transition Confidence Communication Relationships Mindfulness Purpose and Direction Other Terms and Conditions of EngagementConfidentiality and Professional Ethics As an AHHCA member and ICF Professional Certified Coach, I am committed to maintaining high standards of confidentiality, ethics and client care. Your information is kept confidential and stored securely. Brief professional notes are maintained to support your care. Confidentiality may only be limited where required by law or where there is a serious risk of harm. Optional Zoom Session Summary Yes, I would like to receive a confidential written summary of my Zoom session for my personal reference. I understand this summary will be shared only with me and stored securely.Contact Between Sessions Email or text messages may be used for appointment scheduling or brief communication.Scope of the Service This wellbeing service integrates counselling, coaching, mindfulness and communication development. While our work may support emotional wellbeing, personal growth and improved functioning, it is not a substitute for medical, psychiatric or emergency healthcare. Where appropriate, I may recommend consultation with your GP or another qualified health professional.Our Partnership To help you gain the greatest benefit from our work together, we both agree to: My Commitment to you: Provide a respectful, supportive and non-judgemental environment. Listen with care, empathy and professionalism. Respect your autonomy and personal choices. Maintain confidentiality within legal and ethical limits. Work collaboratively towards your goals. Support your growth with honesty, compassion and professionalism. Your Commitment I invite you to: Attend sessions on time. Participate openly and honestly to the extent that feels comfortable. Take responsibility for any actions you choose to implement between sessions. Advise me if your circumstances change. Notify me if you need to reschedule an appointment. Cancellation Policy Your appointment time is reserved exclusively for you. If you need to cancel or reschedule an appointment, please provide at least 48 hours' notice. Appointments cancelled with less than 48 hours' notice, or missed without notice, will incur the full session fee unless there are exceptional circumstances at the practitioner's discretion. This policy helps ensure appointment times remain available for all clients and supports the smooth operation of the practice. Thank you for your understanding and cooperation.Crisis Statement This service is not intended for crisis support. If you require immediate assistance, please contact 000 or your local mental health crisis service.Concerns or Complaints: If you have any concerns about our work together, I encourage you to discuss them with me so we can work towards a resolution.Engagement Agreement and ConsentAgreement and Consent I acknowledge that: I have read and understood this Wellbeing & Personal Development Agreement. I have had the opportunity to ask questions. I understand the nature and purpose of the service being provided. I understand the confidentiality policy and its legal and ethical limits. I voluntarily agree to participate in this process. Agreed Session Length(Required)Agreed Session Fee: AUD $(Required)Name(Required) First Last Signature(Required)Date DD slash MM slash YYYY Practitioner Information:Practitioner Name First Last SignatureDate DD slash MM slash YYYY
