General Agreement and Intake Form

for Therapy and/or Coaching

BASIC INFORMATION
Client Name *
Client Name
Phone *
Phone
Address *
Address
CONSENT AND AGREEMENT
Please acknowledge the following statements
Understanding Coaching vs. Therapy *
Coaching is NOT Therapy. If you reside outside of California, then the nature of our work will be referred to as coaching as my license to practice therapy is restricted to the state I was licensed in. The work we do will look, feel and consist of similar concepts to therapy and my approach to coaching mirrors my therapy style. This agreement indicates we are agreeing to engage in coaching sessions via tele-communication.
Appointments and Cancellations *
Standard appointment times for adults are 50 minutes, and 30 minutes for children. I have a “no cancellation” policy, thus you are responsible to pay the full fee for your scheduled appointment time until termination of therapy/coaching, whether you attend a session or not. If you let me know at least 24 hours in advance that you will be unable to attend I will attempt to offer you a make-up time, at no additional cost.
Payment *
Sessions are paid for after our session through our invoice system with a credit card on file. You will be emailed an invoice at the end of your session to take care of payment or you can choose to keep a credit card on file for your convenience. Payment is due the day of services rendered. Session fees are subject to a yearly increase, and you will have ample notification.
Video Communication *
FOR THERAPY CLIENTS: If we use video communication for our session we will use a HIPPA compliant system such as Zoom or Doxy. If you wish to use FaceTime or other non-HIPPA compliant forms of communication you are waiving your right to HIPPA as it pertains to tele-health. All other measures will still be taken to protect your confidentiality and privacy and best practices will be employed. FOR COACHING CLIENTS: Method of communication will be decided upon between the you and your coach (ie. Zoom, Doxy, Skype, FaceTime, etc.)
Telephone Calls *
There is no charge for phone calls under 5 minutes. Longer calls will be pro-rated at the client’s hourly rate. Frequent calls may indicate a need for an additional weekly session.
Emergency Calls *
I do not have an emergency phone line. I check messages during the week and will get back to you as soon as possible. If you are having an emergency it is important to seek help immediately by going to a hospital or calling 911.
Confidentiality *
FOR THERAPY CLIENTS: Counseling is a unique therapeutic relationship that involves confidentiality, or the client’s right to a confidential relationship with a therapist. A clinical chart is maintained describing your treatment and progress in treatment. These charts and all other information about a client and client’s family are held strictly confidential. NO information can be released without your written permission, except in some situations where California law has mandated that confidentiality may or must be broken: - A mandated report is required when there is a reasonable belief of past or present physical, emotional, or sexual abuse of a minor, or of a dependent adult (handicapped) or elderly person. This is not a choice, but a mandate. - When the court requires a disclosure of records or when you enter into a legal proceeding in which YOU raise the issue of your mental status, then the court may order your records. - When you represent a danger to yourself or threaten to harm another person. FOR COACHING CLIENTS: Since this is a coaching relationship general confidentiality will be maintained out of respect for the nature of the work we are doing, however there are no legal guidelines to coaching and confidentiality.
Confidentiality and Couples and Family Therapy *
Couples and or family sessions may include both joint and individual sessions. In such circumstances the couple or family hereby agrees to waive their right to confidentiality so that information shared in individual sessions can be shared in joint sessions at the discretion of the therapist/coach. To maintain an atmosphere of openness and honesty, my policy is that I am unwilling to collude with secrets, wherein one family member shares information with me that they wish to keep from other family members. Any phone calls received from one family member to the therapist may be discussed in joint sessions to maintain openness and trust.
Confidentiality and Contribution to Knowledge *
I am committed to the advancement of psychology and family therapy, and coaching as a science and a profession. I may contribute professional time to research, teaching, training and improving the standards of psychotherapy. Some of this teaching and writing requires the use of case illustrations. These illustrations are general and do not expose the identity of any person. Unless you notify me to the contrary, it will be assumed that you have no objection to this work in lectures or publications.
Termination of Therapy/Coaching *
I believe you are the best judge of when to terminate therapy or coaching. I will do my best to provide counsel on the matter, but you must make the ultimate decision about continuing care. I will provide you with referrals if you or I feel progress is inadequate.
Record Keeping *
I will keep brief notes of our sessions that will be kept in a locked file so we can review progress.
General Consent to Therapy/Coaching *
FOR THERAPY CLIENTS: You apply for and consent to counseling and diagnostic testing as prescribed. You agree to be responsible for the payment per session which is payable at the time of the session. Any appointment not kept will be charged to you. FOR COACHING CLIENTS: you apply for and consent to coaching. You agree to be responsible for the payment per session which is payable at the time of the session. Any appointment not kept will be charged to you.
Authorization to Keep a Credit Card on File *
If you wish to keep a credit card on file, sessions can be billed to your card for convenience. All information will be kept confidentially through Square Inc., and only used after services rendered.
Your typed name will serve as your signature of acknowledgment that you have read and understood the above statements.
PERSONAL QUESTIONS
Have you had previous counseling? *
Was it successful?
Are you currently taking any medications? *