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Terms and Conditions PROFESSIONAL FEES My standard fee is $200 per the initial 50-minute session and $150/ hour for the subsequent Initial BILLING AND PAYMENTS Payment is expected at the time of each session unless we agree otherwise. In certain circumstances of unusual financial hardship, I may be willing to offer a payment plan option. You will be responsible for all fees connected with my professional services due at the time of services or at termination until all fees are paid. Unpaid fees may be subject to legal action or referral to a collection agency. I utilize an online billing system that allows me to accept electronic checks, cash, and Visa/Mastercard/Discover Cards. An Electronic Payment Authorization form is included with this orientation packet along with an explanation of how your payments will be handled. Please complete this form today and include it with this contract. If you would like a Monthly Statement of Charges and Payments, please also include your email address and one will be sent on the 5th of each month from Therapy Partner, our payment processing system.Initial Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. Client Signature or Guardian if Client is a Minor Date Revisions to above agreement: I agree to revise the above agreement as follows: Dr Joshua L Cohen CEO and Media Psychologist Date I agree to the revision(s) noted above. Client Signature or Guardian if Client is a Minor Date Your Digital Storytelling ProjectDr. Josh Cohen PAYMENT PROCESSING INFORMATION Please complete the following information and return this form to your provider. Session fees for all clinical treatment will be deducted from the account designated on this form and will be noted as a “Your Digital Storytelling Project” transaction on your bank statement. Forms of payment accepted: Visa, MasterCard, Discover, American Express, checks, and cash. This form will be securely stored in your clinical file and may be updated upon request at any ETHNICITY: EDUCATION: Who may I thank for referring you to this office? Name: Other referral source: GOALS FOR LIFE COACHING SESSIONS: COACHING PLAN: OTHER COMMENTS: Dr Josh Cohen: The services provided by Josh Cohen PhD. Include Coaching for Digital Storytelling or TeleCoaching “Digital storytelling is a short form of digital media production that allows everyday people to share aspects of their life stories. The media used may include the digital equivalent of film techniques (full-motion video with sound), animation, stills, audio-only, or any of the other forms of non-physical media (material that exists only as electronic files as opposed to actual paintings or photographs on paper, sounds stored on tape or disc, movies stored on film) which individuals can use to tell a story or present an idea on topics decided jointly with you, The Client. The purpose of coaching is to develop and implement strategies to help you reach personally identified goals of enhanced performance and personal satisfaction.”Coaching for Digital Storytelling does not offer any guarantee of success.Psychotherapy, on the other hand, is a health care service. Its primary focus is to identify, diagnose, and treat nervous and mental disorders. The goals include alleviating symptoms, understanding the underlying personality dynamics which create symptoms, changing the dysfunctional behaviors which are the result of these disorders, and helping patients to cope with their psychological problems.LegalI am not a licensed Psychologist but have training and experience in diagnosing and treating emotional and psychological problems. Although there are some similarities between Digital Storytelling and psychotherapy, I, as The Digital Storyteller, will not conduct psychotherapy under most circumstances with my coaching clients. Digital Storytelling and psychotherapy are different modalities, and it is important that you as The Client understand the differences between them. Although both Digital Storytelling and psychotherapy utilize knowledge of human behavior, motivation, behavioral change, and interactive counseling techniques, there are majordifferences in the goals, focus, and level of professional responsibility.PERSONAL LIFE COACHING SERVICESServices: The services provided by Josh Cohen PhD. Include Coaching for Digital Storytelling or TeleCoaching “Digital storytelling is a short form of digital media production that allows everyday people to share aspects of their life stories. The media used may include the digital equivalent of film techniques (full-motion video with sound), animation, stills, audio-only, or any of the other forms of non-physical media (material that exists only as electronic files as opposed to actual paintings or photographs on paper, sounds stored on tape or disc, movies stored on film) which individuals can use to tell a story or present an idea on topics decided jointly with you, The Client. The purpose of coaching is to develop and implement strategies to help you reach personally identified goals of enhanced performance and personal satisfaction.” Coaching for Digital Storytelling does not offer any guarantee of success. Psychotherapy, on the other hand, is a health care service. Its primary focus is to identify, diagnose, and treat nervous and mental disorders. The goals include alleviating symptoms, understanding the underlying personality dynamics which create symptoms, changing the dysfunctional behaviors which are the result of these disorders, and helping patients to cope with their psychological problems. While psychotherapy may be reimbursable through health insurance policies, Coaching for Digital Storytelling services, at present, are not.It is understood and agreed to by The Client and The Digital Storytelling Coach that if either of us recognizes that you, The Client, have a problem that would benefit from psychotherapy, I, The Digital Storytelling Coach, may refer or direct you to appropriate resources in addition to or in lieu of Digital Storytelling Coaching. In some situations as a condition of my continuance as your Digital Storytelling Coach, I may insist that you enter psychotherapy and that I have your consent to discuss matters which concern you with your psychotherapist. It is further understood that, as The Digital Storytelling Coach, I am not obligated to provide you, The Client, with psychotherapy services.Mutual Nondisclosure: The Digital Storytelling Coach and The Client mutually recognize that they may discuss The Client’s future plans, business affairs, customer lists, financial information, job information, goals, personal information, and other private information. The Digital Storytelling Coach will not voluntarily communicateThe Client’s information to a third party. In order to honor and protect the Digital Storytelling Coach’s intellectual properties, The Client expressly agrees not to disclose or communicate any proprietary information about the Digital Storytelling Coach’s practice, materials, or methods to any third parties. The Digital Storytelling Coach and The Client agree to be bound by this mutual nondisclosure agreement during and after the termination of the Digital Storytelling Coachingrelationship.Dispute ResolutionIt is agreed between The Client, his or her assigns, family and estate, and The Digital Storytelling Coach that any controversy or claim arising out of or relating to The Agreement, or the breach of this agreement, shall be settled by arbitration by an accredited individual or organization with an arbitrator whom we mutually agree upon. And, the arbitration may occur by telephone.Your signature below, as The Client, acknowledges that you have read the information contained in The Agreement and Informed Consent; and indicates your assent to the terms of The Agreement, and signifies your assurance that you will abide by its terms during our professional Digital Storytelling Coaching relationship. The parties to The Agreement will hold duplicate originals of this document which have been signed and dated by both parties.Personal Life Coaching is not easily described in general statements. It varies, depending on the personalities of the coach and the client, and the particular problems you want to address in your coaching sessions. Your feelings about the coaching experience and your Digital Storytelling Coach are very important. I encourage you to discuss any questions, confusion, or frustrations you experience so that they do not become obstacles to meeting your goals. I believe you are the best authority on whether or not a coaching relationship will be helpful. Our first few sessions will involve a discussion of the goals you want to work on accomplishing and the plan of action for meeting those goals. We will work collaboratively to determine the best course of action, to ensure your success in meeting your goals in our work together. If you have any questions or concerns about your work with me, I encourage you to discuss them with me. If you feel that I have been unable to adequately address your questions or concerns, you may contact my supervisor, whose name and number are noted above, directly to discuss them further. BENEFITS and RISKSThis section includes a discussion about the benefits and risks of Digital Storytelling Coaching.The benefits may include reduced stress and anxiety, a decrease in negative thoughts and self-defeating behaviors, improved relationships, increased comfort in social, school and/or family settings, increased self-confidence, and a more hopeful attitude towards life.The risks may include discomfort as we address attitudes and behaviors that may be contributing to the problems you have presented. As your Digital Storytelling Coach, I may from time to time challenge your assumptions or perceptions and offer a different perspective. Changes in your perspective, thoughts or feelings may have unintended outcomes, including changes in personal relationships. During the course of our work together, it is often the case that you will feel worse before you feel better; this is natural and expected in any coaching process. Personal growth is sometimes difficult and slow, and sometimes easy and swift. When we sign this agreement together, I commit to helping you through the entire process of Digital Storytelling Coaching. This will mean helping you to achieve the goals you initially state, but other issues or problems may arise during the course of our work together that will require further exploration. If this happens, we will work together to revise the goals as appropriate and work towards a satisfactory solution of your problems. There is no guarantee that Digital Storytelling coaching will yield any or all of the benefits listed above. Neither is there any certainty that the risks listed above will be encountered during the course of our work together. Digital Storytelling Coaching is an open and dynamic process, and its course is dependent upon our mutual willingness to collaboratively continue the process and, to a certain extent, upon life events that cannot be foreseen. InitialCONFIDENTIALITYThe privacy of all communication between a client and a Digital Storytelling Coach is expected and I will only release information about our work to others with your written permission. However, there are a few exceptions. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that you are a danger to yourself or others or if a child or an elderly or disabled person is being abused, I am required to file a report with the appropriate state agency. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. InitialAPPOINTMENTS AND CANCELLATIONSDigital Storytelling Coaching sessions last 50 minutes and are typically scheduled on a weekly basis. Appointments must be made in advance. If you are unable to keep your scheduled appointment, I ask that you provide at least 24 hours notice. Once an appointment hour is set, this time is set aside for you, and thus, you will be expected to pay the full session fee unless you provide advance notice of cancellation. Printed First Name Last Name Date

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