Miche Wilson: Health History and Consent Forms

Consent for Treatment:

The purpose of the Client Agreement is to give you some insight into the approach that I use and what you can expect from participating in a coaching/mentorship relationship with me, make you aware of your rights and responsibilitites as a client, and my rights and responsibilities as a Coach, Facilitator and Clinical Counselling Hypnotherapist, including confidentiality.

Please read this document carefully and if you require any clarification before signing, do not hesitate to contact me. By signing below, you agree to the terms and conditions set out in this Client Agreement.

During all meetings, the therapis will advise and make recommendations in consultation with the client, and based on presenting issues and concerns. Ultimately, the client decides which services are most appropriate at which time. No type of therapy will ever be intiated without the client's fully informed consent. More detailed information on services is provided in meetings with clients and on the website www.michewilson.com.

I consider myself to be an Integrative Practioner. Please refer to my website noted above or this link for more information about my background and training: www.michewilson.com/about-5.

My Approach:

Though the scope of my practice extends way beyond the strict definition of coaching/mentorship, I refer to coaching as the overall process used to work towards your goals, independent of the modalities applied. I rely on my years of knowledge and intuitive guidance, often utilizing more than one aspect of the above training, bringing in a fusion of modalities as determined required.

The intention of each session is to identify your goals, and the potential blocks or limiting beliefs preventing the attainment of these goals. We then develop tools and resources to support you as you walk towards your goals, starting from wherever you are on your journey and depending on the struggle or dilemma you bring into the session. My hope is to support you in releasing patterns and habits that no longer serve you, while implementing new ones that do. My approach is both holistic and client centered – I look at you as a whole being, not as the sum of parts and symptoms. Often during the coaching process layers may be released that reveal underlying root causes, limiting beliefs or blocks that are no longer serving you or might be self-sabotaging mechanisms to the goals you are desiring to work towards. As every client’s needs are unique, Schedule A of this Client Consent sets out the specifics of your Client Agreement.

At the end of a session, if you have not yet mentioned what steps you are ready to take, I may make a coaching request. I will ask you to stretch yourself, deepen and integrate the work done in the session. You are free to negotiate, accept or decline – this is your time, your life, your process. You are in charge of all of your decisions and/or actions within our working relationship, and outside of it. I will guide you to the best of my abilities but you remain in charge of you.

Your Role:

Come to each session hydrated, with an open heart and mind, and ready to receive. Be radically honest about where you are at and what you’re feeling and experiencing. That is the start of transformation! All of you is welcome and accepted - You cannot do ‘you’ wrong.

You’ll get as much out of the coaching process as you put into it. Please arrive to every session on time. I invite you to be curious and willing to try new approaches. I encourage you to experiment and allow yourself explore new ideas about life, your pain and struggle. Give yourself permission to release or adjust beliefs and habits if they do not serve you anymore. Give me feedback in the moment about your coaching experience - what works, as well as what does not.

It is important for you to understand that you are the primary decision-maker in the direction your life’s journey takes, and therefore you have the right to full and active participation in the decisions that affect you.

In addition, you have the right to:

• Receive an appropriate referral to other resources as needed.
• Accept or reject any task or exercise suggested by me.
• Be made aware of the rationale, risks, and benefits of any and all coaching interventions.

As you are the primary decision-maker, you agree that I am not and will not be liable or responsible for any action or inaction, or any direct or indirect result based on the services I provide to you.

Payment for Treatment:

Due to the importance of holding space for each client, full payment is required at least 48 hours prior the start of sessions to reserve your spot. Specific instructions are in Schedule A to this Client Agreement. Payment can be made by e-transfer to michewilson1111@gmail.com; or, using Stripe by credit card, the latter being subject to an additional administration fee of 3%. I will send you confirmation of your booking upon receipt of payment. All fees are exclusive of applicable taxes and may be subject to withholding taxes, depending on your location.

Cancellation Policy:

We have a 48 hour (2 business day) cancellation policy to allow us ample time to offer your appointment to another patient in need of it. A fee may be charged for missed appointments or failure to reschedule before the 48 hour time limit. I will not reschedule no call/no shows; if you fail to meet me on the call at our scheduled time it will be a loss of session. I do not provide refunds.

Should you be late for any reason the time will be deducted from your session in respect of my time and other clients that may be scheduled before and after your session. By my electronic signature below, I agree to the terms and conditions.

I understand the consent for treatment, the payment and cancellation policies as stated above. 

Schedule A

Session Procedures

Each session will be via Zoom and the link will be sent to you directly through Calendly, the scheduling software of my practice, including a reminder 24 hours prior to each session. I invite you to honour yourself and give your sessions high priority and arrange your schedule to prioritize you and your needs. I honour your time as I honour mine and other clients’ schedule.

Confidentiality

Although this relationship is not considered a legally confidential relationship (like the medical and legal professions) and thus communications are not subject to the protection of any legally recognized privilege, I shall not disclose any of your personal information or personal health information with any other parties without your written consent, unless required to do so by law, for example:

• If you have provided written permission to share your information.
• The courts subpoena my files.
• I am subpoenaed as a witness in court.
• I suspect cases of child abuse that have not been previously reported. This includes physical harm, sexual abuse, sexual exploitation, and emotional harm.
• If you threaten to harm yourself or another. In this case I am also required to report this to the proper authorities.

I shall hold personal information provided by you in accordance with The Personal Information Protection and Electronic Documents Act (Canada) and the EU General Data Protection Regulation, if applicable.

During the coaching process I may collect personal information provided by you via telephone, emails, interviews, or intake forms. You acknowledge that the purpose of collecting this information is to assist me in gaining an in-depth understanding of your current situation and be able to accurately assess all factors influencing and contributing to your presenting issue. My questions also intend to empower you by increasing your own awareness which can open up the possibility of choices that might be supportive on your journey towards your goals. I also collect any information that I feel would assist us in our coaching relationship to explore and deepen awareness of underlying root causes of issues and empower you with tools to reduce physical and emotional stress in your body. Details of information to be collected depends on the presenting issues and the goals which are unique to each individual. 

You are in control of what personal information you provide to me and you hereby consent to my collection, use and storage of all personal information you do provide to me.

Upon completion of our coaching relationship, I shall retain your personal information for a minimum period of 2 years and a maximum of 3 years. After this period, all files including personal information will be deleted from my computer and back-up device.

I use utmost care in protecting personal information. Though I have taken technical precautions to the best of my knowledge and ability, please be advised that any information contained in email form cannot be totally guaranteed confidential. By providing me personal information via email you acknowledge this risk and confirm that I shall not be liable for any loss, embarrassment or damages of any kind whatsoever resulting from a breach of personal information sent via email or electronically.

Your email address will never be shared, sold, or rented to anyone.

By signing this agreement, you consent to the collection, use and disclosure of your personal information as set out in this article. 

Intellectual Property Rights:

You recognize and agree that the copyrighted and original materials you receive from me are for your individual use only. All such materials provided or made available to you are the intellectual property of Miche Wilson, and Miche Wilson is and shall remain the sole owner/proprietor of all such materials. You are not authorized to, and shall not share, copy, distribute, alter, or otherwise disseminate in any way any materials received from Miche Wilson electronically or otherwise without Miche Wilson’s prior written consent. No license to sell or distribute Miche Wilson’s materials is granted or implied by this Client Agreement or the provision of coaching services and the materials may only be used strictly in accordance with this Client Agreement.

You may download and/or print any materials for your personal use. “Materials” includes any audio, video, printed or written text or work created by me that are provided to you strictly for our work together, or for your educational and informational purposes. To clarify, you are not permitted to share, sell, reprint, reproduce or republish any other of our materials including handouts, for resale or reproduction purposes for your own business or commercial use or in any way other than for the use contemplated by this Client Agreement.

Disclaimer:

Please note that working with me does not replace the need for your healthcare providers. My services are not intended to act as a replacement for certified medical or regulated psychological care and I make no claims that receiving any of my services will cure any illness. I do not diagnose conditions, nor perform medical treatment nor interfere with the treatment of a licensed medical professional.

Consult your physician or health care professional regarding particular health matters. I disclaim any liability arising directly or indirectly from any information given or received during your consultation(s) with me. Any liability is limited to the cost of the programmed sessions.

I MAKE NO GUARANTEES, REPRESENTATIONS OR WARRANTIES OF ANY KIND OR NATURE, EXPRESS OR IMPLIED WITH RESPECT TO THE SERVICES PROVIDED. IN NO EVENT SHALL I BE LIABLE FOR ANY DIRECT, INDIRECT, CONSEQUENTIAL OR SPECIAL DAMAGES, WHETHER ARISING OUT OF CONTRACT OR TORT. NOTWITHSTANDING ANY DAMAGES THAT YOU MAY INCUR, MY ENTIRE LIABILITY UNDER THIS AGREEMENT, AND YOUR EXCLUSIVE REMEDY, SHALL BE LIMITED TO THE AMOUNT ACTUALLY PAID BY YOU UNDER THIS AGREEMENT FOR SERVICES RENDERED.

You hereby agree to indemnify me and hold me, my heirs, successors or assigns harmless from and against any or all damages, actions, costs, fees, expenses or losses (including any legal fees or other professional costs or expenses) arising in connection or in relation to the services I provide or this client agreement.

This client agreement and Schedule “A” attached hereto represent the entire agreement between you and I and reflects the complete understanding of the services. This client agreement supersedes any previous written agreement and any verbal agreements. This client consent cannot be altered or amended except by written agreement signed by both you and I and it shall be governed by the laws of the Province of Ontario.

If any dispute may occur relating to the application, interpretation, implementation or validity of this Client Agreement, you agree to resolve such dispute or controversy solely through mediation in accordance with the Canadian Mediation Association. The costs of the mediator shall be shared equally by each of us and such mediation shall be held in Toronto governed by the laws of the province of Ontario, Canada.

I understand the terms outlined in the above document labeled Schedule A around Session Procedures, Confidentiality/Privacy, Intellectual Property Rights, Disclaimers/Liability and all the details within. By signing below, I indicate that I have fully read, understand, and agree with the above terms.