Informed Consent Form Logo
  • Informed Consent Form

    COUNSELING/COACHING
    Informed Consent Form
  •  - -
  • Soulciety61|LeAnzar Stockley, M.A., Counseling Services

    We're a relational wellness organization with extensive experience in counseling, coaching and support group facilitation, geared toward psychosocial & psychospiritual alignment. Our unique approach, called Relationality Alignment, is a transformative healing method that addresses wholeness in life relationships, spirituality, and mental health. It guides individuals, couples and groups towards support, breaking free from unhealthy patterns and disharmonious societal norms; enabling them to embrace their core essence of oneness and love for more fulfilling connection(s).

    Our counselors hold graduate-level degrees and are trained in counseling, mental/behavioral health and the Grief Recovery Method. It's important to note that while our approach is therapeutic, it differs from formal therapy provided by licensed therapists, psychologists, or psychiatrists. We do not possess licensing from a licensing board. However, we are Board Certified Mental Health Coaches and specialize in various coaching niches.

    We highly value our relationship with clients, viewing it as a crucial aspect of the counseling/coaching process. Recognizing each individual's uniqueness, we endorse a wellness model that supports and empowers clients to focus on what works for them, rather than following a one-size-fits-all approach to treatment.

  • Client's Rights

    1. Unless there is an emergency, all the counseling/coaching sessions are private and confidential with the exception of specific exceptions described below:

    a. Child, elder or dependant abuse,

    b. Expressed threats of violence toward an ascertainable victim,

    c. Detailed planning or concrete signs of future suicide attempts,

    d. Sharing information is necessary to facilitate client care across multiple providers,

    e. Sharing information is necessary for the counseling process,

    f. Requests from legal and administrative institutions.

     2. With the Client's prior written consent, the Counselor may legally speak to another healthcare provider or Client's family members in emergency situations. The Client may direct the Counselor to share information with whomever the Client desires, and the Client may change his/her mind anytime and revoke the permission.

     3. The Counselor is allowed to keep brief notes of the session which shall be kept in strict confidence. The Client may, at any time request a copy of the notes kept during the session.

    4. The Client may ask questions on what to expect during and end result of the counseling/coaching.

    5. The Client may decline to proceed the counseling/coaching as to the techniques which may be conducted by the counselor.

    6. The Client may cease to continue counseling/coaching anytime, without any impediment and may return to counseling anytime.

    7. The counselor has the right to dismiss the Client from the course of counseling/coaching.

  • Payments

    The Fee Schedule can be found for your reference at www.leanzarstockley.com/soulciety61, located within the relevant services section. Prior to each session, payment is anticipated, unless alternative arrangements have been mutually established. Please take a moment to conscientiously review and confirm your commitment to adhere to the prescribed fee structure or any agreements reached with a company representative.

  • Acknowledgement

    • I have reviewed and accept this Counseling/Coaching Informed Consent Agreement. 
    • I have reviewed and agree to the Support Group Guidelines and Agreement (if applicable).
    • I have carefully reviewed and hereby acknowledge my commitment to remit payment for services in accordance with the established fee structure.
    • I am aware that payment is expected prior to each session (groups are charged by the month), unless alternative arrangements have been mutually agreed upon.
    • I understand that cancellations are expected 24 hours in advance of the scheduled appointment time; otherwise fees will not be refunded (unless otherwise approved by Soulciety61 staff).
  • Powered by Jotform SignClear
  •  - -
  • Should be Empty: