couples tele/e\class
	Agreement Form
Step One  [agreement form]   Step Two  [registration information]   Step Three  [payment]	The consumer [you, the couple] agrees to the following:
	1.  We understand that we are committing to the entire 4-week tele-e-class and we agree to participate fully for the entire process.
	2.  We understand that though Michele O'Mara, LCSW is a liscensed mental health therapist, this program is not therapy or psychological counseling and is this is not a substitute for intensive couples therapy provided in-office.  If we desire therapy or psychological counseling, we will seek services in-person from a licensed provider.
	3.   We are emotionally well (free of suicidal or homicidal thoughts and feelings) and we commit to being responsible for our own well being during the course of this tele-e-class.  Further we agree that neither of us has not been clinically diagnosed with Borderline Personality Disorder or Dissociate Disorder.  The format and style of this class is not well-suited for persons with these particular menthal health conditions.
	4.  We understand that this teleclass is for my personal benefit only and may not be appropriate for others. We understand and agree that successful completion of this teleclass does not constitute professional training and does not entitle me to teach, lead, coach or otherwise use this material with others in any way.
	5. We understand that all materials used in this course are confidential and proprietary in nature and other than for my own personal use, we retain no future right to use these materials or processes in any way without express permission by Michele O'Mara, LCSW, LLC.
	6. We affirm that we have answered all questions on included on this application form honestly, and we have fully disclosed all the information requested. We assume all risk associated with participating in this teleclass and release the teleclass leader, Michele O'Mara, LCSW, and shall defend, and indemnify, and hold them harmless from and against, all liabilities, claims, actions, losses, causes of action, and costs in any way arising out of my participation in the program.
	7.  We understand that we are responsible for notifying Michele O'Mara if we choose to leave the course prior to completion. We also understand that payment is non-refundable.
	8.  We have read and comprehended the above stated agreements.  It is understood by both of us that this is not mental health treatment.  We are fully aware that the Provider is based in Indianapolis , Indiana and is governed by the law accordingly.
	We have read and understand this agreement fully and intend to be legally bound by it.  Our continuation to step two constitutes our acceptance of the conditions expressed in this agreement. We Agree To The Terms Outlined Here | Return Home