Welcome to Supportive Mental Wellness, LLC mental health coaching services with Vivian Echeverria Quiroga.
This informed consent and waiver document contains important information about mental health coaching services and related business policies. Please read it carefully and let me know if you have any questions.
By signing below, I understand and acknowledge all of the following:
Disclosure: Vivian Echeverria Quiroga (heretofore referred to as “Coach”) is not a licensed physician, psychologist or other provider of medical or psychological services in your state or any other state. The services offered by Coach are alternative or complementary to healing arts services licensed by your state.
Disclosure: Supportive Mental Wellness, LLC is a separate entity from Julie Wilmot's business, Supportive Wellness, LLC.
Payment: I understand that payment for sessions must be received before or at the start of a session. I understand that it is in my best interest to take care of payment before my session starts so I am not spending session time on administrative business, which will optimize the time I have to work on my mental health and wellness goals.
Coach’s education, training, experience, and other qualifications are as follows:
- Certified brainspotting practitioner: Specialty training in expansion brainspotting and brainspotting with adolescents
- Provide advocacy, promoted safety, shaped wellness systems, provided wellness education and personalized wellness interventions at: Pennsylvania Hospital; The Wedge Recovery Center; Kirkbride Rehabilitation Center; Children's; Hospital of Philadelphia; Fairmount Behavioral Health System; Penn Presbyterial Medical Center; Lankenau Medical Center; University of Maryland Medical System; Catholic Charities; John Hopkins Hospital
- Specialty training in: Children and Residential Experiences; Therapeutic Crisis Intervention (TCI); Trauma Informed Care; Handle with Care Behavior Management System
- Undergraduate degree, University of Pennsylvania
- Post graduate studies, Duke University
Nature of Services: Coach supports an individual's journey towards mental, physical, social, and emotional betterment through: emotional and psychological methods that may include psychoeducation about nervous system wellness, parts work, and brainspotting; exercises related to nervous system wellness, parts work and brainspotting.
Mental health coaching is not therapy and is not medical treatment: I understand that most states do not prohibit individuals from offering coaching services. However, states require a license in their state to practice medicine and therapy to undertake the diagnosis, prevention, treatment, or cure of any disease, pain, deformity, injury, or physical or mental condition and require a license to state that any product or service might cure any disease, disorder, or condition. Thus, in the role of coach, Coach does not offer therapy, or therapeutic diagnoses. I understand that Coach does not diagnose, treat, or claim to do any medical or psychological treatment and that Coach’s services are not designed to replace conventional treatment methods of medical or psychological conditions. I also understand that Coach does not offer therapy for emotional or mental disorders. I have chosen to work with Coach and understand that the information received should not be seen as medical, nursing or counseling advice and is not meant to take the place of seeing a licensed health professional.
No guarantee: I recognize that Coach cannot guarantee results or any specific outcomes from our work together. I am solely responsible for any action taken based on my interpretation of any information presented.
Right to discontinue services: I understand that Coach has the right to refuse to continue delivering services at any time for any reason whatsoever and will refund the client’s advance payment for the portion of unused services. I understand that I have the right to discontinue services at any time.
My responsibility for health care: I understand I am responsible for my own health care decision-making by obtaining any necessary consultations with appropriately licensed health care professionals such as physicians and psychologists. In case of an emergency, I will call 911.
My responsibility for my self-care: I understand that any relational or inner-directed work, or self-reflection can bring up distressing symptoms, feelings, images, thoughts and behaviors. I agree to seek medical assistance or psychotherapy or any other appropriate physical or mental diagnosis and treatment from a practitioner duly licensed in my state of residence (such as a licensed medical doctor or licensed psychologist) if I find that these distressing aspects create a danger for myself or for others.
Confidentially: I understand that the session content and all relevant material to coaching will be held confidential unless I request in writing to have all, or portions of such content, released to a specifically named person/persons. I understand that limitations of confidentiality exist and are itemized below: If Client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm; If Client threatens bodily harm or death to another person; If Coach has reasonable suspicion that Client is the perpetrator, observer of, or victim of physical, emotional or sexual abuse of a child or elderly person; If a Court of law issues a subpoena for information stated on the subpoena.
Consent for Telehealth Services: Should I choose to receive services via telehealth, I hereby consent to receive healthcare services through Zoom with Supportive Mental Wellness and Vivian Echeverria Quiroga as my coach. I understand telehealth services may involve video conferencing, audio, and/or other electronic communication to connect me with Coach. I understand that telehealth services may offer certain benefits, such as increased access to mental health and wellness services and reduced travel time and costs. However, I also understand that telehealth services may have limitations in the quality and security of electronic communication, and the potential for technical difficulties. I understand that Coach will make every effort to ensure the security and privacy of my personal information, however, I acknowledge that there are risks associated with electronic communication and that my information could be intercepted or disclosed without my consent.I understand that I have the right to withdraw my consent for telehealth services at any time. I understand that Coach has the right to terminate telehealth services at any time if they determine it is not in my best interest.
Minors: I understand that Coach takes a minor's privacy very seriously, but if Coach is concerned about the minor's safety, well-being or the safety or well-being of others, this Coach is obligated to share the necessary information with me as the minor's guardian. I trust the discretion of Coach to determine if/what information would be shared with the me as the minor's guardian. I understand that Coach will make every effort to discuss with the minor in advance regarding what information will be shared with you as their guardian, but there may be a situation where this is not possible.
Social Media: I understand that to maintain confidentiality, Coach does not accept “friend” or contact requests via social media to a personal account, only to a Supportive Mental Wellness professional account.
Assumption of Risk: I knowingly, voluntarily, and intelligently decide to receive the services described above, and I knowingly, voluntarily, and intelligently assume all risks involved in the same. As a result of my assumption of these risks, I agree to release, hold harmless, indemnify, and defend Coach and her agents from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the services described above, or arising out of or in connection with recommendation to other practitioners or merchants for delivery of any services.
Case Consultation: According to the ethics of the coaching profession, topics may be anonymously and hypothetically shared with other coaching professionals for training, supervision, mentoring, evaluation, further coach professional development and/or consultation purposes.
Cancellation: I understand if I give Coach less than 2 hours notice to cancel a session, I will be charged the full cost of the session but will be given a credit for one telehealth session at a future date. I understand that a pattern of giving Coach less than 48 hours notice to cancel a session may impact Coach’s ability to reliably schedule future appointments.
Financial Responsibility: I understand that Coach does not accept insurance or negotiate with insurers, and that Coach’s services are not reimbursed by any insurer. I am financially responsible for my session and agree to pay the charges incurred before or during the time of service.
Coach’s availability: I understand that Coach is often not immediately available by telephone, text or email and does her best to reply to calls, texts and emails as soon as possible. I understand that sending a text is the most reliable way to communicate with Coach and Coach will make every effort to return my message as soon as possible, usually within 24 hours, with the exception of weekends and holidays.
Voicemails and texts: I understand that voicemail and email alerts on cell phones are unreliable and text messages are more reliably seen by Coach. I understand that Coach’s preference is to communicate via text and Coach will respond to any voicemails or emails via text, if appropriate.
Please read the following and sign below:
I acknowledge that I have received, have read (or have had read to me), and understand the information about the mental health coaching services I am considering.
I have had all my questions answered fully and agree to abide by the terms outlined above.
I assume all risks of the recommendations made by Coach.
I understand that using mental health coaching services at Supportive Mental Wellness with Coach is not a form of psychotherapy and that Vivian Echeverria Quiroga acting as a mental health coach, not as a licensed psychotherapist or licensed counselor during mental health coaching sessions, and that I can stop services at any time.
I acknowledge and take full responsibility for my life and well-being, as well as the lives and well-being of my family and children (when applicable), and all decisions made during and after these services. I understand that no promises have been made to me as to the results of mental health coaching services.
With a full understanding of the potential risks, I hereby assume the risks of participating in mental health coaching with Coach. I affirm that I alone am responsible to decide whether to make any life decisions or changes based on the work done with Coach. I hereby agree to irrevocably waive, release and discharge any claims and/or liabilities for death or personal injury or damages of any kind that I have now or hereafter may have against Coach and Julie Wilmot with Supportive Wellness, LLC as it is a seperate entity. I agree to not sue any of the persons or entities listed for any of the claims or liabilities that I have waived, released or discharged herein.