General Information
The coaching relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding of how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by providing your signature at the bottom of this page.
The Coaching Process
You have taken a very positive step by deciding to seek coaching. The outcome depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeat patterns, as well as to help you clarify what it is that you want for yourself.
- Coach agrees to maintain the ethics and standards of behavior established by the International Coach Federation ("ICF"). It is recommended that the Client review the ICF Code of Ethics and the applicable standards of behavior.
- Client is solely responsible for creating and implementing his/her own physical, mental and emotional well-being, decisions, choices, actions and results arising out of or resulting from the coaching relationship and his/her coaching calls and interactions with the Coach. As such, the Client agrees that the Coach is not and will not be liable or responsible for any actions or inaction, or for any direct or indirect result of any services provided by the Coach. The client understands coaching is not therapy and does not substitute for therapy if needed, and does not prevent, cure, or treat any mental disorder or medical disease.
- Client further acknowledges that he/she may terminate or discontinue the coaching relationship at any time, understanding that there are no refunds for unused sessions.
- Client acknowledges that coaching is a comprehensive process that may involve different areas of his or her life, including work, faith, finances, health, relationships, education, and recreation. The Client agrees that deciding how to handle these issues, incorporating coaching principles into those areas, and implementing choices is exclusively the Client’s responsibility.
- Client acknowledges that coaching does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association and that coaching is not to be used as a substitute for counseling, psychotherapy, psychoanalysis, mental health care, substance abuse treatment, or other professional advice by legal, medical or other qualified professionals, and that it is the Client’s exclusive responsibility to seek such independent professional guidance as needed. If the Client is currently under the care of a mental health professional, it is recommended that the Client promptly inform the mental health care provider of the nature and extent of the coaching relationship agreed upon by the Client and the Coach. F. The Client understands that in order to enhance the coaching relationship, the Client agrees to communicate honestly, be open to feedback and assistance, and to create the time and energy to participate fully in the program.
Confidentiality
The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
- If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.
- If a client threatens grave bodily harm or death to another person.
- If the coach has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
- Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
- Suspected neglect of the parties named in items #3 and # 4.
- If a court of law issues a legitimate subpoena for information stated on the subpoena.
- If a client is in coaching or being treated by order of a court of law, or if the information is obtained for the purpose of rendering an expert’s report to an attorney.
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best care for you. Information about you may be shared in this context without using your name.
If we see each other accidentally outside of the coaching session, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the coaching session.
PAYMENT FOR SERVICES
Payment must be made in full, or according to the agreed-upon payment plan, in order to book your session. This coaching agreement is valid as of the date this form is signed. If rates change before this agreement has been signed and dated, the prevailing rates will apply.
Refunds
There are no refunds after the first session or for unused sessions.
Package Limits
All packages automatically expire within 6 months of purchase, except for 12-month packages.
Session Cancellation & Rescheduling Policy
You may cancel or reschedule your sessions at least 48 hours in advance with no penalty. All sessions missed will be subject to a full charge. For sessions canceled or rescheduled with less than 48 hours notice will be billed at half the session rate. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you will lose that portion of the session time. If you are more than 5 minutes late to a session, except due to extenuating circumstances, the session will be canceled without a refund. For equine-assisted sessions, the length of the session will be cut short and may result in not working with a horse. If you have canceled or rescheduled more than three sessions in a six-month period, you will be automatically billed a $25 cancellation and rescheduling fee to hold the date for your next session.
Weather Policy for Equine-Assisted Sessions
Due to the nature of the work with horses for equine-assisted sessions, the following weather policy is in place to accommodate for the unexpected variable of the weather. The decision to cancel, reschedule, or relocate a session due to weather is at the discretion of Stable Minded for the safety of participants. Since weather can change at a moment's notice, there may be situations in which a session at the farm can not include a horse. There will be no refunds for the change in such a session. If the forecast predicts temperatures below 40 degrees, snow, ice, severe rain, or wind more than 8 miles per hour, sessions will be moved online for a Zoom session or moved to an indoor space. If you prefer to only have sessions with the horse, please keep an eye on the forecast and request rescheduling at least 48 hours prior to your session.
Session Locations
EQUINE-ASSISTED LOCATION
For all sessions at Honey Brook Stables (80 King Rd, Honey Brook, PA 19344) please park adjacent to the arena and text me at (443) 256-9493 when you arrive. I will provide instructions for where to meet me. Please note you will receive a Zoom link for your sessions. Please save this link in case it is necessary for when the Weather Policy (see below) is in effect.
ONLINE LOCATION
Please note that online sessions take place via Zoom. You will receive a link automatically and reminder emails about your session.
Equine-Assisted Session Requirements
PROPER ATTIRE
Clients are advised to wear hard-soled shoes and pants in and around the stables and while working with or riding horses, so as to help prevent horse-related injuries. Open-toe shoes are not allowed in the stable area in the fields, or on horseback. From time to time, you may have the opportunity to experience horseback riding. If so, the Client agrees to use an ASTM-SEI Equestrian-approved helmet, which is required while mounted.
PRESENCE OF EQUINE-ASSISTANTS
Equine-assisted coaching sessions are facilitated by a mental health coach or therapist with the support of an equine partner and an equine specialist. The equine specialist responsibility is to provide support to the horse and safety for participants. This equine specialist abides by the confidentiality policies stated below.
Communication
TELEPHONE ACCESSIBILITY
If you need to contact me between sessions, please leave a message on my voicemail. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that Face-to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept new friend or contact requests from current 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 coaching relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
ELECTRONIC COMMUNICATION
I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:
- You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
- All existing confidentiality protections are equally applicable.
- Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
- Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
- There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to treatment, better continuity of care, and reduction of lost work time and travel costs. Effective treatment is often facilitated when the healthcare provider gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. The provider may make assessments, diagnoses, and interventions based not only on direct verbal or auditory communications, written reports, and third-person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in services, potential risks include, but are not limited to the provider’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the provider not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the provider.
Release of Information
HOW I MAY USE AND DISCLOSE INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose information. For each category of uses or disclosures, I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
Coaching & Counseling Credentialing and Supervision: The Coach engages in training and continuing education pursuing and/or maintaining Coaching Credentials. That process requires the names and contact information of all Clients for possible verification by coaching certification bodies. By signing this agreement, you agree to have only your name, contact information and start and end dates of coaching shared with staff members and/or other parties involved in this process for the sole and necessary purpose of verifying the coaching relationship; no personal notes will be shared.
Lawsuits and Disputes: As a mandated Pennsylvania State Reporter, I am obligated by the law to report certain situations, which include:
- If you threaten to do harm to yourself or someone else.
- If you report knowledge of or participation in sexual and/or physical abuse of children or elders.
If you are involved in a lawsuit, I may disclose information in response to a court or administrative order. I may also disclose information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
- Session Notes: I do keep “Session notes” and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising associates to help them improve their clinical skills.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the session notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
- When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
- For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
- For health oversight activities, including audits and investigations.
- For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
- For law enforcement purposes, including reporting crimes occurring on my premises.
- To coroners or medical examiners, when such individuals are performing duties authorized by law.
- For research purposes, including studying and comparing the patients who received one form of care versus those who received another form of care for the same condition.
- Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
- For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
- Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
MINORS
If you are a minor, your parents may be legally entitled to some information about your treatment. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
Termination of Services
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after an appropriate discussion with you and a termination process if I determine that the treatment is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If treatment is terminated for any reason or you request another provider, I will provide you with a list of qualified professionals to treat you. You may also choose someone on your own or from another referral source. Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.
Limited Liability
Except as expressly provided in this Agreement, the Coach makes no guarantees, representations or warranties of any kind or nature, express or implied with respect to the coaching services negotiated, agreed upon and rendered. In no event shall the Coach be liable to the Client for any indirect, consequential or special damages. Notwithstanding any damages that the Client may incur, the Coach’s entire liability under this Agreement, and the Client’s exclusive remedy, shall be limited to the amount actually paid by the Client to the Coach under this Agreement for all coaching services rendered through and including the termination date.
Entire Agreement
This document reflects the entire agreement between the Coach and the Client, and reflects a complete understanding of the parties with respect to the subject matter. This Agreement supersedes all prior written and oral representations. The Agreement may not be amended, altered or supplemented except in writing signed by both the Coach and the Client.
Dispute Resolution
If a dispute arises out of this Agreement that cannot be resolved by mutual consent, the Client and Coach agree to attempt to mediate in good faith for up to 30 days after notice given. If the dispute is not so resolved, and in the event of legal action, the prevailing party shall be entitled to recover attorney’s fees and court costs from the other party.
Severability
If any provision of this Agreement shall be held to be invalid or unenforceable for any reason, the remaining provisions shall continue to be valid and enforceable. If the Court finds that any provision of this Agreement is invalid or unenforceable, but that by limiting such provision it would become valid and enforceable, then such provision shall be deemed to be written, construed, and enforced as so limited.
Waiver
The failure of either party to enforce any provision of this Agreement shall not be construed as a waiver or limitation of that party's right to subsequently enforce and compel strict compliance with every provision of this Agreement.
Applicable Law
This Agreement shall be governed and construed in accordance with the laws of the State of Pennsylvania without giving effect to any conflicts of laws provisions.
Binding Effect
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By providing your digital signature, you are acknowledging that you have received a copy of the HIPAA Notice of Privacy Practices.