CLIENT CONSENT AND AUTHORIZATION

Consent to Coaching:

I hereby consent to receive online couples' coaching from Northampton Center for Couples Therapy (hereafter referred to as NCCT). I understand that my consent is voluntary. I also understand that I do not have to accept any coaching option NCCT offers and that I may withdraw my consent at any time. 

I accept that working towards change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach my coaching goals. I understand that the changes I make will have an impact on my partner and others around me. I accept that such changes can have both positive and negative effects and agree to clarify and evaluate potential effects of changes before taking them [This is especially true if dependent children are involved]. On the other hand, couples' coaching is also been shown to have many benefits. Couples' coaching often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. 

Online Couples' Coaching:

ONLINE COUPLES' COACHING is a collaboration between the couple and the coach to create an action plan for improving your relationship. 

At NCCT, our well-trained coaches will equip you with effective relationship tools that you can start implementing immediately in order to produce the results you desire.

ONLINE COUPLES' COACHING is often a more short-term, focused approach that fosters awareness, encourages accountability, and instills practical relational skills for the couple to utilize going forward. We know from research that online treatment can be very effective for relationship coaching and believe this could be the path for you if:

• You want to improve your relationship
• You feel stuck and don’t know how to move forward 
• You’ve considered separation or divorce
• You’re tired of fighting about the same thing over and over…

ONLINE COUPLES' COACHING is a unique service and is not the same as regular couples therapy. I understand by choosing ONLINE COUPLES' COACHING, I am agreeing to the following:

• I understand 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. 
• I understand that it is my exclusive responsibility to seek independent professional guidance as needed. 
• I understand that while coaching can work with issues such as identifying and reaching life goals, and changing behaviors that aren't working well for me, coaching cannot deal with issues such as depression and/or anxiety. 
• I understand that although I as a client may have a mental health diagnosis, coaching is not intended as a treatment or cure for that condition. 
• I understand by signing this agreement, I understand the difference in these two functions and that I will get appriopriate professional guidance if necessary. 

Online Coaching Sessions: 

I understand that by choosing online coaching, I am agreeing to the following:

• My online coaching session must be conducted using the platform chosen by NCCT. Any other means of communication will not be allowed for my online sessions unless initiated by my coach.
• Technology limitations can cause interruptions in my online sessions. These limitations can include but are not limited to; hardware problems, software issues, Internet connection/speed, power outage, etc.
• Confidentiality and privacy are dependent on a quiet, uninterrupted environment. There should be no other unidentified individuals in the room during my remote online session. If there are others in the room, they must be disclosed and all parties involved in my session must be made aware and consent to their presence.
• During my online coaching session, there can be possible misunderstandings when visual cues are absent in communications. Seating and lighting should be tailored to allow maximum comfort to all involved in the session.
• Clarity and visibility of the person(s) at the other end of the video services should be maximized.
• Computers/cameras used during my online coaching session should be on a secure, stable platform to avoid any movement interruption during the video session.
• I must provide an alternate phone number to my coach in the event of an interruption of my session.
• My coach may request the contact information of a family member or community member who could be called upon for support in the case of an emergency.
• My coach may also request to know if I have any limitations in terms of travel to local emergency services.
• The computer I use for my online coaching sessions has up to date antivirus protection and a personal firewall is enabled.
• My online coaching sessions will be not be recorded unless I give my consent and authorization.

I also understand that there are circumstances in which online coaching may not be the best treatment option for me. Such circumstances may include when there is:

• An undisclosed, ongoing or recent affair.
• Active addiction (drugs, alcohol, etc.).
• Serious violence in my relationship, threats of serious violence or fear of serious violence on the part of one or both partners.
• An untreated, diagnosable mental illness (bipolar, psychotic disorders and major clinical depression). This does not include past and successfully treated mental health conditions that are currently stable and/or in remission.
• Suicidal or homicidal thoughts, or a history of serious harm inflicted on another person.
• Lack of commitment to the coaching process.

I further understand that NCCT may choose at any time to discontinue services in the event that any of these circumstances are present, and at such time all fees paid to NCCT to date (regardless of duration of treatment) are nonrefundable. I understand that in such circumstances NCCT will make a good faith effort to provide me with alternative referrals for alternative professional guidance, but that ultimately it is my responsibility to seek out and pursue professional guidance.

Confidentiality: 

I understand that our communications are private and protected by law. Because of laws protecting confidentiality, in most situations my coach cannot share information about our work without my permission. However, there are certain specific limits to confidentiality. I fully understand these limits below.

1. In order for NCCT to function, my coach may share some of my protected information with staff for purposes such as scheduling and billing. All administrative staff are trained to protect my privacy and have agreed to be bound by the rules of confidentiality.
2. NCCT has a contract with a billing service. As required by HIPAA, NCCT has a formal business associate contract with this business, in which it promises to maintain the confidentiality of data except as specifically allowed in the contract or otherwise required by law.
3. There may be times during our work when, in order to support progress toward my goals, my coach will consult with a colleague or supervisor. My coach will do this in a way that minimizes identifying information. All mental health professionals with whom my coach consults are bound by the rules of confidentiality.
4. Generally, if I am involved in legal proceedings, my coach cannot provide any information about our work without my permission. There are exceptions and, if I anticipate being involved in litigation, I should consult my attorney to determine whether a court could order my coach to disclose information.
5. If I file a complaint or lawsuit against my coach, my coach may disclose relevant information pertaining to me in order to defend himself/herself.
6. If, in the course of our work, my coach has reasonable cause to believe that any child under the age of 18 is being (or has been) physically or emotionally harmed in any way (either because of abuse--including sexual abuse--or neglect) the law REQUIRES my coach to file a report with the Massachusetts Department of Children and Families. My coach will inform me if he/she finds that he/she must file a report.
   Similarly, if my coach has reasonable cause to believe that an elderly person (age 59 or older) or a handicapped person of any age is (or has been) suffering from abuse, the law REQUIRES that my coach file a report with the appropriate authorities.
7. Finally, if I let my coach know that I intend to harm myself or intend to harm another person and my coach believes the risk is real, my coach may be REQUIRED to break confidentiality by contacting the police, alerting the intended victim, contacting a family member, and/or seeking my hospitalization without my consent.

Communication and Availability: 

Due to my coach's work schedule, my coach is often not immediately available by telephone.

When my coach is unavailable, an automated voice mail answers his/her telephone. My coach will make every effort to return my call on the same day I make it, with the exception of weekends and holidays. If I will be difficult to reach, I will inform my coach of some times when I will be available. In a life-threatening emergency, I will call 911 or go to the nearest Emergency Room.

I understand that email is not a secure medium for communication and my coach's preference is that I contact him/her by phone. However, if I choose to contact my coach's using email, I am doing so with the full understanding that my coach cannot guarantee the safety and security of that communication, despite NCCT taking all possible action to protect my privacy.

I also acknowledge that email occasionally disappears or is delayed and that my coach may never receive an email that I send. For example, canceling a session via email is not an appropriate method of notification. My coach recommends that in order to give adequate 24-hour notice of such cancellations, I do so by phone.

Financial Obligation:

I understand that I am responsible for full payment of all fees for my online coaching services provided by NCCT. I understand that my insurance will not cover online coaching sessions. Payment must be made before my session can begin.

Court Action Policy and Fees:

Clients are discouraged from having The Northampton Center for Couples Therapy subpoenaed or requesting records for the purpose of litigation. We are trained in clinical social work, marriage and family therapy, relationship coaching and mental health counseling and our work and therapeutic philsophy comes from non-adversarial positions. We have not been trained forensically or with the expertise to appear in court. We are unable to guarantee that any testimony that we are required by law to give will be solely in your favor. We can only testify to the facts of the case and our professional opinion.

If any clinician at The Northampton Center for Couples Therapy is to receive a subpoena then the attorney or office staff will need to call our office and set up a time for the subpoena to be served during office hours. We request a minimum of 72 hours notice of any Court appearance so that schedule changes for our clients can be made within a reasonable time frame.

Please note: if a subpoena is received without a minimum of 72 hour notice there will be an additional $300 express charge.

Court action fees are as follows:

1. Preparation Time: $260 per hour (billable in 15-minute increments)
2. Phone Calls: $260 per hour (billable in 15-minute increments)
3. Filing Document with court $100
4. Minimum charge for court appearance $1,000.00 for half day, $2,500 for full day
5. Attorney fees: I agree to pay all attorney’s fees and costs that are incurred by The Northampton Center for Couples Therapy as a result of any court action.
6. Retainer: A retainer of $1,500.00 is due at least 72 hours before the scheduled appearance. The remainder of the costs will be billed after the court appearance and will be due upon receipt.

All fees are doubled if the clinician from The Northampton Center for Couples Therapy is scheduled to go out of town.

If a clinician is subpoenaed and the case is reset with less than 72 hour notice prior to the beginning of the day of the scheduled subpoena and or testimony is not given then the client will be billed $1,000.

Bills for court related actions are presented to clients on a weekly basis and payment is expected upon receipt. A zero balance will need to be kept at all times.

ACKNOWLEDGEMENT

My signature below acknowledges that I understand and accept the terms and conditions of this authorization and agreement. 

Cancellation Policy: 

I am required to give a minimum of 24 hours notice if I need to cancel or reschedule our couples coaching session. Initial deposits are refundable when a cancellation occurs four or more weeks before our scheduled appointment. Cancellations after this period will be charged the full fee for the Online Couples' Coaching session, plus related session-specific services.

Additionally all cancellations regardless of notice will incur any credit card processing fees that NCCT incurred in processing Online Couples' Coaching deposits.

 

 

 ACKNOWLEDGEMENT 

My signature below acknowledges that I understand and accept the terms and conditions of this policy. 

 

The Northampton Center for Couples Therapy (NCCT) and its Billing Agency* are authorized to keep my signature on file and charge my account for any balances due from NCCT services rendered to me or my family. I understand that this authorization will remain in effect until NCCT has received written notification from me of it’s termination in such time and manner to afford NCCT a reasonable opportunity to act on it.

I am also authorizing NCCT and its Billing Agency to use the above listed credit card for my partner/spouse for all balances on their account as well. I know that this is in addition to the balances on my account. My signature above authorizes NCCT to apply balances from my spouse/partner's account although my spouse/partner's name is not on the credit card being used at this time.