COACH-CLIENT SERVICES AGREEMENT
This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have about the procedures. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time.
Coaching is not easily described in general statements. It varies depending on the personalities of the coach and client, and the particular presenting problems. There are many different methods I may use to deal with the issues. Coaching calls for a very active effort on your part. In order for the coaching to be most successful, you will have to work on things we talk about both during our sessions and at home.
Coaching can have benefits and risks. Since coaching may involve discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, coaching has also been shown to have many benefits. It often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.
Our first session will involve an evaluation of your needs. By the end of that time, I will be able to offer you some impressions of what our work will include if you decide to continue with coaching. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Coaching involves a significant commitment of time, money, and energy, so you should be very careful about the coach you select. If you have questions about my procedures, we should discuss them whenever they arise.
Our first session will be primarily information gathering. During that time, we can both decide if I am the best person to provide the services that you need in order to meet your coaching goals. I usually schedule one 30-minute session (one appointment of 30 minutes duration) every 2 weeks at a time we agree on.
My standard fee is $150 per session for coaching.
Due to my work schedule, I may not be immediately available by telephone. While I am usually in my office during working hours, my phone calls are always automatically routed to my confidential voice-mailbox. I retrieve and return all messages as soon as possible. At night, and on weekends and holidays, there may occasionally be a somewhat longer time period before I can get back to you, since I may be engaged in an activity that makes returning your call difficult to do right away. If you are difficult to reach, please inform me of some times when you will be available to reach
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a client and a coach. In most situations, I can only release information about your to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where I am permitted or required to disclose information without either your consent or Authorization:
- If you are involved in a court proceeding and a request is made for information, I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
- If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.
There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice.
- If I know, or have reason to suspect, that a child under 18 is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare, the law requires that I file a report with the Department of Child and Family Services. Once such a report is filed, I may be required to provide additional information.
- If I know or have reasonable cause to suspect, that a vulnerable adult has been or is being abused, neglected, or exploited, the law requires that I file a report with the central abuse hotline. Once such a report is filed, I may be required to provide additional information.
- If I believe that there is a clear and immediate probability of physical harm to the client, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or seeking hospitalization of the client.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.
I take and keep Coaching Notes. These Notes are for my own use and are designed to assist me in providing you with the best coaching. While the contents of Coaching Notes vary from client to client, they can include the contents of our conversations, your action plan, and future goals. These Coaching Notes are kept securely, are not available to you and cannot be sent to anyone else, without your written, signed Authorization.