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institute for life & care
participant information

Thank you for taking this opportunity to let us know a bit about yourself.

5. Do you give ILC permission to contact you via text message? (Please note typical carrier rates may apply)
6. Please select your gender.
7. Please select your age range.
10. What is your greatest intention in taking the THRIVING FROM WITHIN® program? Select all that apply.
11. Non-Discrimination Statement: The Institute for Life & Care does not allow discrimination against and harassment of any employee, vendor, or participant because of race, color, national or ethnic origin, age, religion, disability, sex, sexual orientation, gender identity and expression, veteran status or any other characteristic protected under applicable federal or state law. All personnel who are responsible for hiring and promoting employees and for the development and implementation of ILC programs or activities are charged to support this effort and to respond promptly and appropriately to any concerns that are brought to their attention.
12. Care & Guidance: If and by choosing individual care and guidance, you are choosing to continue your meaning-making journey. Nancy Markham Bugbee and the ILC Team promises to do their very best to support you in finding meaning in your life circumstance.
13. Confidentiality: Should you choose one-on-one mentoring sessions, the content of those sessions and all relevant materials will be held confidential, except in situations where there is concern for your safety or the safety of others.
14. Fees & Cancellations Policy: The costs for Level 1 or Level 2 of the TFW® program are $150.00 each, payable on the ILC website at lifeandcare.org. For individual mentoring with Nancy Markham Bugbee, the cost is $115 per 45 minute session for TFW® clients, or $150 per 45 minute session for non-TFW® clients, payable on completion of the session by cash or check. We realize your time is valuable, and we ask that you respect ours as well. If you need to cancel an appointment, please do so at least 24 hours ahead of time. We may initiate communication by email or text message for the purpose of reminders, assignments or setting appointments only. Please do not provide any confidential information over email or texts as these modes are not secure. However, if it is necessary to communicate confidential information via these modes, you accept the risk associated with these modes not being secure. We do not provide clinical care. If at any point you feel the need to speak with a mental health professional, please request a referral. If you find yourself needing immediate mental health intervention, please call Rocky Mountain Crisis Partner at 1-844-493-TALK (8255), call 911, or go to the nearest emergency room.
15. Intellectual Property. THRIVING FROM WITHIN® is an original model of personal growth and professional development. It is not to be reproduced in any form or shared with anyone without the written permission of both the Institute of Life & Care and Nancy Markham Bugbee.
16. Acknowledgement & Signture. I have read the preceding information. I understand the disclosures that have been made to me and my rights as a client. I understand that consistent with HIPPA requirements, this consent form will expire after 12 months, and I may revoke such consent at will, although revocation is not retroactive. I also acknowledge that I have received a copy of this Disclosure Statement.

Thank you for your time!

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