INFORMED CONSENT STATEMENT FOR PSYCHOTHERAPY AND COACHING
Coaching is a relationship that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy and coaching, you have certain rights that are important for you to know about because this endeavor is about your well-being. There are also certain limitations to those rights that you should be aware of. As a coach, I have corresponding responsibilities to you, too.
MY RESPONSIBILITIES TO YOU AS YOUR COACH
With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior written permission. Under the provisions of the Health Care Information Act of 1992, I may legally speak to another health care provider or a member of your family about you without your prior consent, but I will not do so unless the situation is an emergency. I will always act so as to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with whomever you chose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend a therapy session with you. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA).
If you elect to communicate with me by email at some point in our work together, I am willing to respond briefly by return email, but please be aware that email and other electronic media are not completely confidential. I do not use an encrypting program on email at this time.
The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect.
- If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.
- If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.
- If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or the county crisis team. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.
- If you and your partner decide to have some individual sessions as part of the couples therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. Do not tell me anything you wish kept secret from your partner.
I keep brief records of each session noting the dates we meet, the topics we cover, progress reports from the client’s perspective, interventions and impressions from the therapist and next steps. My records are kept private and not shared with others, in accordance with HIPPA requirements.
III. OTHER RIGHTS
You have the right to ask questions about anything that happens in therapy. I’m always willing to discuss how and why I’ve decided to do what I’m doing, and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns, and can request that I refer you to someone else if you decide I’m not the right therapist for you. You are free to end consultations at any time, although I recommend finding a way to give me advance notice so that I can help you end this process well and consolidate gains.
As of 9/1/19: Individual therapy or couples therapy is $125 per 50–60-minute session. You will be asked to pay for each session at the time of the session. Payment can be by check, cash, credit card or PayPal. There is no direct billing with any commercial insurance company, as coaching is not covered by insurance.
V. SOCIAL MEDIA
I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
VI. ENDING WELL
I want to make your journey with me as successful as possible. For that reason, it works best to find a rhythm and structure to the beginning stages with sessions that meet regularly. To support your leaving, I request several weeks of notice prior to your actual leaving to allow you to have an experience of leaving well, with a sense of completion. If I initiate the ending of coach-client relationship, it will be because I feel that I am not able to be helpful to you any longer. If I no longer feel that I am the best or right practitioner for you, I will offer referrals to other sources of care, but cannot guarantee that they will accept you.
VII. MY TRAINING AND APPROACH TO SERVICES
I am a certified coach. I provide humanistic approach to the individual and couples’ therapy. I use elements of EFT, Narrative therapy and SFT.
I hold MA in Clinical Mental Health Counseling with emphasis in Couples and Family Therapy from William James College.
Several times a year I attend conferences out of town. If I am not taking and responding to phone messages during those times, I will have someone cover my practice. I will tell you well in advance of any anticipated lengthy absences.
There are potential benefits and risks of video-conferencing (e.g., limits to client confidentiality) that differ from in-person sessions.
Confidentiality still applies for telepsychology services, and nobody will record the session with-out the permission from the others person(s).
We agree to use the video-conferencing platform selected for our virtual sessions, and the coach will explain how to use it.
You need to use a webcam or smartphone during the session.
It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
It is important to use a secure internet connection rather than public/free Wi-Fi.
It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the psychologist in advance by phone or email.
We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation.
If you are not an adult, we need the permission of your parent or legal guardian (and their con-tact information) for you to participate in telepsychology and coaching sessions.
YOUR RESPONSIBILITIES AS A CLIENT
You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 50 minutes. If you are late, we will end on time and not run over into the next person’s session.
If you miss a session without canceling, or cancel with less than forty-eight (48) hours’ notices within business hours (Monday-Friday), you will be charged for that session, unless I can reschedule with you within the same calendar week.
If you’re unhappy with what’s happening in therapy, I hope you’ll talk about it with me so that I can respond to your concerns. Please see sections on this page re: ending services.
Starting coaching sessions with Pearl Morgovsky signals agreement with these policies. You may also be given an additional policy to review and sign in the office.