CONTRACT

PLEASE PRINT AND SIGN and send by email.

A Personal Responsibility Agreement and Contract is a written and
signed agreement between you and the CAROLINE HALLAK program. You agree that: CAROLINE HALLAK assistance is temporary. CAROLINE HALLAK program benefits are NOT to be used for alcohol, illegal drugs, gambling, or other purposes not intended to meet basic needs.

You are hereby confirming that our recommendations are suggested here, to be used and practiced.

NO GUARANTEE OR PROMISES OF ANY RESULTS: ________ Just initial.

NO REFUND, NO CANCELATION AT ANY TIME:         ________ Just initial.

To our knowledge, you are doing the work as best as you can.

You agree that maybe you are going to succeed, or maybe you will not during the week program booked hereby. It might take you a little longer, or much longer time to attain your results:                                          ________ Just initial.

You agree that it will take your effort and work to get results: _________ Just initial.

Signature : ______________________ Date: ________________

Sign here if you want us to interfere during our 1:1 contact, in case a need arises, such as an emergency or a suicide issue, we can call 911 to get you help. We will require all your info, such as;
Address:

Phone number:
And where you might be in other locations, as well as an additional emergency contact, such as parents, friends or a significant other: if you want to involve them;
Your relationship:
Address:
Other phone number:
Or singing this contract as confirming ANY THOUGHTS OF SUICIDE that have ever occurred in the past or present.

Full Name: __________________________________________

Address: _____________________________________________

Signature : ______________________ Date: ________________