Zachary Ross Alti, LCSW P.C.
Coaching Client Service Agreement and Consent
In the following document, "client" shall refer to the signee of this document. "Coach" shall refer to the coach of services.
Zachary Alti and associates are proud to provide you with personalized support. Please read and sign the following agreement; it lists our practice policies and procedures. If you have any questions, please don’t hesitate to ask for clarification.
Please note, this agreement is for coaching services only. If you are seeking therapy, please notify a representative of Zachary Ross Alti, LCSW P.C. before signing this form.
Clients will be given a weekly slot. Additional sessions and reschedules (see the cancellation section below for rescheduling within 24 hours of the appointment start time) can be booked on our website, www.zacharyalti.com, using the yellow "book online" button.
If you schedule an appointment or communicate with coach via email or text message, you are consenting for coach to respond to your email or text utilizing the same method, even if you have not completed the email and text consent you will receive in conjunction with this agreement.
Once a weekly session is scheduled, you will be expected to pay for it unless you provide 1 business day (24 hours, excluding weekends and holidays) advance notice of cancellation. Cancellations and re-scheduled sessions will be subject to a full cash pay rate charge if NOT RECEIVED AT LEAST 1 BUSINESS DAY, 24 HOURS IN ADVANCE. If you provide notice within 1 business day as outlined above, I may extend flexibility at my discretion to find another time to reschedule the session. If you miss a session without any prior communication, you will be charged the full cash pay session fee regardless. If you are late for a session, you may lose some of that session time or be subject to the cancellation fee. This is necessary because a time commitment is made and held exclusively for you.
If canceling an appointment that is not a weekly scheduled session, a client must give notice of cancellation no less than 48 hours prior to the session start time. If canceled within 48 hours of the session start time, the client will be responsible for an $80 fee.
If canceled within 24 hours of the session start time, the client will be responsible for the full fee of the session.
If cancellation is due to illness, these rules may be waived upon presentation of a doctor's note. If cancellation is due to personal tragedy, these rules may be waived upon presentation of documentation attesting to the event/occurrence. Waiving of these rules is at the sole discretion of the coach.
The coach will make every effort to provide you with a minimum of 24 hours advance notice when they need to cancel or reschedule a session. However, the coach reserves the right to cancel a session at any time for any reason and without penalty. You will not be charged for any cancellation initiated by the coach. However, if the coach must cancel a session, they will do their best to find a time to reschedule in order to ensure you continue to receive care and minimize disruption to your services.
Clients may opt to terminate services at any time. It is considered a best practice to terminate services intentionally with a minimum of one session to provide closure, summarize progress, and discuss recommended next steps for services and growth past the termination of the client's active status in the practice.
A minimum of one session per month (four weeks) is required to maintain an active status as a client. If a four week period passes with no session the client will be automatically withdrawn from the client list and will have to re-enter as a new client if they wish to restart services (Unless discussed in advance with- and waived by- the coach.). Return is subject to coach availability, and re-entry as a client will be subject to all rules, procedures and fees at the time of re-entry, regardless of the state of these rules, procedures and fees at the time of termination.
Should you miss three consecutive sessions, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.
In order to offer unfilled slots to clients who need one, reschedules require notice before the session, or notification as soon as possible in cases of emergencies.
Coaching clients are subject to the same lateness policy as therapy patients of the practice, which is based on billing codes and is as follows;
Lateness past 7 minutes for individual sessions and past 4 minutes for couples sessions will result in activation of the cancellation fee.
Should the coach’s schedule allow for an extension of the session past the originally scheduled end time, allowing for the client and coach to meet for the minimum session length, this fee may be waived.
For other professional services you may need on an hourly basis I charge at a rate of $300/hour, though I will break down the hourly cost in increments of 20 minutes if I work for periods of less than one hour. Services requiring less than 20 minutes will be subject to a flat $100 fee. Other services include but are not limited to report writing, phone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or services summaries, and the time spent performing any other service you may request of me.
Payment schedules for other professional services will be calculated as outlined in this document or otherwise agreed to when requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. In these cases, you must provide a written request detailing your situation in writing. I may request supporting documentation and approve or deny any such request at my discretion.
Billing and Payments
In order to facilitate payment of fees, I and/or a third party providing administrative and billing support for Zachary Ross Alti, LCSW P.C. may retain your payment information (e.g. credit card, debit card, bank account, or other information for the purpose of payment) and may enroll you in auto-pay with your consent. Any financial information retained will be maintained as confidential information.
You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment for services rendered will be charged to the payment method we have on file for you at the conclusion of each coaching session. If I find that your payment does not go through, I will request that you review and update your payment information prior to attending your next appointment.
If your account has not been paid for more than 30 calendar days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through a small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information released regarding a client’s services is their name, the nature of services provided, and the amount due.
Failure to make payment will result in termination of service. Failure to settle unpaid balances may result in enlistment of a collections agency, and may affect creditworthiness. A balance of two unpaid sessions will result in a lock out from future services until the balance is settled.
Payment is the sole responsibility of the client regardless of a third-party payer's declared coverage of any portion of session costs.
Third Party Payment:
You are responsible for full payment of the fees.
If your benefits run out during the course of your coaching and you continue to attend sessions, you will be responsible for any and all fees, including full cash pay rate session fees.
It is important to remember that you always have the right to pay for services yourself to avoid the problems described above.
The coach will provide a monthly invoice to clients who request it. This invoice can be used to seek third- party reimbursement for coaching. The coach may help the client to communicate with and seek payment from the third-party payer. The degree of this assistance is at the discretion of the coach based on time, availability, and appropriateness of the support.
Cost of Services:
Coach's rate for a session is set. Rates are as follows;
Standard "45 minute" (38-52 minute) couples coaching session- $390
26-30 minute couples coaching session- Prorated
53+ minute couples coaching session- Prorated
Standard "45 minute" (38-52 minute) individual coaching session- $300
16-37 minute individual coaching session- Prorated
53+ minute individual coaching session- Prorated
This fee may be lowered if the client qualifies for- and agrees to- the coach's income/debt-based sliding scale. If so, please list the agreed upon rate at the bottom of this document before signing.
Rates may also be lowered if client opts for phone (rather than video) sessions.
Session frequency is at the discretion of the client, though a weekly appointment is needed to guarantee slot availability.
There are currently no restrictions on the sharing of information collected by coaches, but this practice adheres to the same standards of confidentiality and privacy required by law for both coaching clients and therapy patients. Information may be released in the following circumstances;
• Risk of Harm: If a client conducts themselves in a manner that either (a) threatens or (b) directly attempts to cause serious bodily harm to or kill themselves or someone else.
• Abuse: If the coach has a reasonable suspicion that a client or another named victim is the perpetrator, observer, or actual victim of physical, emotional, or sexual abuse.
• Vulnerable Individuals: Suspicions of abuse as stated above in the case of an elderly person, child under the age of 18 years, protected class, or any other vulnerable persons who may be subjected to these abuses or come to harm due to neglect.
• Complying with the Law: If a court of law issues a legitimate subpoena for information stated on the subpoena, if a client is in coaching or services by order of a court of law, in cases involving workman’s compensation, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
In such cases I may be required to, for example, take protective actions such as contact police, report abuse to the appropriate state agency, seek hospitalization for a client at risk or threatening to harm himself/herself or others, or notify a victim. I may at times contact family members and/or others who can ensure the safety of anyone at risk of serious harm or death.
I will make every effort, within my own ability, to discuss it with you before taking any action. However, if there is an immediate concern to someone's health or safety, I may not be able to have this discussion prior to taking action. I may occasionally find it helpful to consult other professionals about a case to ensure you receive high quality care. During a consultation, I make every effort to avoid revealing the identity of my client(s). Ordinarily, I will not tell you about these consultations unless I believe that it is important to our work together.
While this written summary of exceptions to confidentiality is designed to help inform you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney. You will be responsible for any costs associated with seeking legal advice.
If you become involved in a legal matter (e.g., divorce, custody dispute, etc.), it is important to understand and agree that Zachary Ross Alti, LCSW P.C. and its coach(s) do not provide evaluations or expert testimony in court.
If you disregard this provision and choose to involve Zachary Ross Alti, LCSW P.C. or its coach(s) in any and all legal/court related matters, or if another party involves Zachary Ross Alti, LCSW P.C. or its coach(s) in a legal matter involving you, you agree to provide compensation, in the form of payment as outlined below, according to provisions as stipulated:
• Paying at the rate of $500 per hour for preparation and professional time.
• Paying in advance for a minimum of five hours ($2,500.00) and within ten days for any additional hours.
• You further realize you will be billed for hours including: preparation, travel, court attendance, and phone time; legal counsel sought regarding your court case, etc.
If you as a client, file a complaint/legal suit against Zachary Ross Alti, LCSW P.C., its staff, coach(s), and/or a third party engaged in support of your coaching services, you authorize us to fully disclose any and all relevant information regarding our services to you in our legal defense and you hereby waive any right to confidentiality and privacy.
You agree to indemnify and hold harmless Zachary Ross Alti, LCSW P.C., its coach(s) and any party engaged to support your coaching services. You also agree to indemnify and hold harmless its shareholders, officers, directors, employees, representatives, agents, and successors from and against any and all loss, damage, expense, liability, claims, or demands brought by any party whatsoever, arising out of or related to any failure of technology or equipment in connection with the provision of coaching services or administrative tasks whether or not any such loss, damage, expense, liability, claim, or demand arises from or relates to their negligence.
In the event that Zachary Alti is summoned to court or any other legal arena on behalf of the client, there will be a $500.00 per hour charge with a maximum of $4000.00 per day.
By signing this form you acknowledge and agree to the use of anonymized content from your sessions for the purpose of clinical trainings, presentations and publications.
Anonymized content is content where identifying information has been removed.
Identifying information is information such as names, non-general locations, names of employers and other unique identifiers of a client which could be used to identify the client. In certain cases the coach may wish to further obscure the identity of the client and so may include non-relevant changes to specifics in the content (such as clients first name or initials, field of work, etc. if deemed necessary to ensure anonymity).
This agreement includes content retroactive to the signing of this form as well as future content.
Services may be provided in an office, via telephonic communication, via virtual platform or via other setting as services dictates. The client assumes all responsibility for their personal safety in whatever environment services takes place in. The client waives all legal discourse for any accidents, injuries, or harm that occurs as a result of the coach, services or environment.
Standard sessions are 38 minutes for individuals and 26 minutes for couples. Quoted fees reflect these session lengths. Sessions may be scheduled in blocks of 16 minutes, 26 minutes, 38 minutes, and 53 minutes. Longer or shorter sessions may be also be requested and will be pro-rated based on the quoted fee.
Typically the first 1-2 sessions for any new client/couple will be 45 minutes in length to account for extra time needed for history taking, goal setting, etc.
Recommendations and Suggestions:
The sessions conducted are for the purposes of coaching only. Recommendations for therapeutic practices such as meditation, exercise etc. may be given by Zachary Alti or his staff during services. The client acknowledges that all recommendations are optional. The client may ask any questions they have about these recommendations and can choose to reject or discontinue the recommendations at any time. Liability for any risk, injury, or damage endured by the client as a result of these recommendations is assumed wholly by the client.
Any suggestions offered by Zachary Alti or staff are intended to be treated as anecdotal. Nothing said by Zachary Alti or his staff is intended to be taken as legal, financial, or nutritional advice. It is understood by the client that Zachary Alti and all staff performing coaching services under the purview of Zachary Ross Alti, LCSW P.C., are acting in a role of coach, not therapist or doctor, regardless of their other licenses and training. All services and exercises are optional. All suggestions are only suggestions, and should be thoroughly researched independently by the client(s).
Content from any individual session(s) performed with the identified client or family member of the identified client within the scope of couples/family services is not guaranteed to be held as confidential. The coach may elect to make every effort to hold this information as confidential in most and potentially all cases, but cannot guarantee confidentiality of information shared within an individual session due to the plain logistics of information collection and services administration for the couple/family system.
It is difficult to slow down and give our minds a chance to detox from the stimulation of the day. In an effort to maintain a consistently calm and productive tempo, and avoid volatility in energy availability which would negatively impact the equitable nature of service to all clients our coaches do not ingest caffeine in excess of 50mg within 3 hours prior to a coaching session. We also ask our clients to refrain from caffeine use in excess of 50mg for at least one hour before and during sessions as the difference in tempo could negatively impact services.
A coach's office is not equipped to handle psychological emergencies. If you are at risk of hurting yourself or someone else, call 911 to receive the acute help and care that you need.
If you are experiencing an emergency in-session, the coach may advise you to seek emergency medical care, such as a psychiatric evaluation at a hospital.
As stated above in the confidentiality section of this document, appropriate support, medical, legal, correctional, security, or police involvement may be initiated by the coach if the coach believes the client to pose a reasonable threat to the safety of themselves or others in the future.
By signing this form, you acknowledge that you have read this document and understand the risks, benefits, and alternatives of participating in coaching services. You also acknowledge that you have read and agree to the Practice Policies outlined herein and have been given ample opportunity to ask questions which have been answered to your satisfaction. You further acknowledge and understand that:
• Your coach will determine whether coaching is appropriate for you based on your specific condition and needs.
• Results are not guaranteed, and you may or may not benefit from the coaching services.
• You will be informed of any charges associated with the coaching services prior to incurring any charges and you agree that you are responsible for paying the full amount of all costs associated with the coaching services provided to you.
By signing this document you also acknowledge that you understand the risks, benefits and alternatives of receiving these services and have had the opportunity to ask questions of your coach.
If any provision of this agreement, or any application of any provision of this agreement, is held to be invalid, or to violate or be inconsistent with any federal law or regulation, that shall not affect the validity or effectiveness of any other provision of this agreement, or of any other application of any provision of this agreement, which can be given effect without that provision or application; and to that end, the provisions and applications of this agreement are severable.
By signing below I acknowledge that I have read and understand this service agreement and consent form, and agree to abide by the policies stated herein. I have thoroughly considered all of the above information, and I have obtained whatever additional input and/or professional advice I deem necessary in making an informed decision regarding these office policies and disclosures.
IF SIGNING ELECTRONICALLY AND/OR CHECKING THE BOX TO INDICATE A SIGNATURE, YOU CONSENT TO PROVIDE A DIGITAL SIGNATURE.