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:
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:
Online Coaching Sessions:
I understand that by choosing online coaching, I am agreeing to the following:
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:
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.
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.
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.
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:
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.
My signature below acknowledges that I understand and accept the terms and conditions of this authorization and agreement.
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.
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.