INFORMED CONSENT
1. WELCOME TO MY PRACTICE: HOW THINGS WORK
Welcome to my coaching practice. This document contains important information about my coaching services and business policies. When you sign this document, it will represent an agreement between us. We can discuss any questions you have when you sign the document or at any time in the future.
2. COACHING
Coaching is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in coaching, you have certain rights and responsibilities which you need to understand. There are also legal limitations to those rights that you should be aware of.
3. RISKS AND BENEFITS
Coaching has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of coaching often requires discussing the unpleasant aspects of your life.
However, coaching has been shown to have benefits for individuals who undertake it. Coaching often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. There are no guarantees with regards to the outcome of coaching. Coaching requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss - outside of sessions.
4. LIMITS OF CONFIDENTIALITY
I have been advised by Dr. Dunn that at all communications with me and all records relating to the provision of coaching services to me are confidential and may not be disclosed without my written consent.
I have also been advised by Dr. Dunn about limits on the confidential nature of the coaching service provided to me.
- If I present an imminent danger to myself or others the law requires that steps be taken to prevent such harm;
- If a child is in need of protection a report must be filed with the appropriate agency or authority;
- If a vulnerable adult is abused or neglected a report may be filed with the appropriate government agency;
- If a court orders the disclosure of records.
I do attend regular supervision where I may discuss your case with my supervisor or consultant; however I will always maintain your anonymity. I also attend regular professional development so that you may get the best possible help. I will keep encrypted case notes of your sessions on a secure password protected computer and will delete these after 6 years.
5. CONSULTATION TIMES
My Coaching Practice is open from Monday to Thursday between 09:00 and 17:00. If you need a coaching session after 17:00 the cost is 1½ times the normal fee. I am not available on Fridays, weekends or public holidays.
6. COACHING SESSIONS
Coaching sessions will once per week / every second week at a time we agree on. The time scheduled for your coaching session is assigned to you and you alone. You are responsible for arriving on time; if you are late, your coaching session will still end on the scheduled time.
During a coaching session you can expect my undivided attention. I usually take notes so that I am sure that I don’t overlook anything that is of importance.
During a session, you will find that I often use silence. At first you will probably be uncomfortable with it but I want to encourage you to use silence as a way of exploring what you are experiencing in your body- what are you becoming aware of and how intense is that feeling. When we are constantly busy, we miss the information that our body gives us.
To get the most of your coaching session, I want to encourage you to be open about what you are feeling, your thoughts and experience. A lot will probably go through your head during the coaching session. If you are not sure about something, please ask. The more you understand the coaching experience and how it works, the more comfortable you will be. It is also important to have realistic expectations with regards to changes that you expect within yourself. It is important to realize that coaching takes time and commitment.
As we begin, it is good to know the benefit of coaching is that you might find a way to start reaching your goals. This might involve naming what isn’t working and trying new ways of dealing with your life. The work you do in coaching is a bit like putting together a toolkit. You have a chance to learn a whole bunch of new skills, so that when life gets hard, you can figure out which “tool” will best help you handle the problem or feeling. There are also challenges involved in coaching. For example, when I ask you to look at hard topics or times in your life, you may feel stronger than usual emotions. It may feel strange to try out some of the new skills that I suggest, and you may be surprised to find out some people in your life aren’t really supportive of what you are learning.
If at any time during the course of your coaching I determine I cannot continue, I will terminate coaching and explain why this is necessary. Ideally, coaching ends when we agree you have reached your goals. Additional conditions of termination include:
- You have the right to stop coaching at any time. If you make this choice, referrals to other coach can be provided.
- Professional ethics mandate that coaching continues only if it is reasonably clear you are receiving benefit.
- Other legal or ethical circumstances may arise and compel me to terminate coaching. In these cases appropriate referral(s) will be offered. Also, I do not diagnose, treat, or advise on problems outside the recognized boundaries of my competencies.
- Other situations that warrant termination include: regularly becoming enraged or threatening during session; bringing a weapon onto the premises; persistent drug abuse; arriving under the influence of drugs or alcohol; disclosing illegal intentions or actions.
As the end of the session is approaching, I will inform you that we have to wrap up as we can’t go over the scheduled time. Kindly note that if for whatever reason we go over the time, you will be billed for that time in 10 minute intervals.
7. CANCELLATION OF COACHING SESSIONS
All coaching sessions must be cancelled at least forty-eight (48)hours before the scheduled time otherwise a full coaching session will be charged for in full. If a Monday coaching session is cancelled it must be done so by 12h00 the preceding Friday. Should I fail to arrive for any scheduled coaching session at the appointed time, I acknowledge that I will be liable for the full fee of that coaching session.
No-shows and late cancellations (less than forty-eight (48)) hours prior to the coaching session time or after 12h00 the preceding Friday if my coaching session is on a Monday) will be charged for in full, regardless of the reason (no refund will be issued in the case of clients who have settled their account in advance), and all upcoming coaching sessions will be cancelled until payment is received for the outstanding balance. Should any coaching sessions which have been paid in advance be cancelled at least twenty-four (24) hours in advance, on in the case of a Monday coaching session, the preceding Friday by 12h00, the client will receive a full refund for the coaching session, or the payment will be carried over to the next booked coaching session.
The booking system that you used to book this appointment will send you a reminder if you entered all your information correctly. This is just to remind you of the coaching session. I have no control over technology with regards to delivery of the message. You will still be responsible to attend your coaching session even in the event of the sms not reaching you.
8. FEES AND NON-PAYMENT OF FEES
The standard fee is R1500 per session ranging from 50 to 90 minutes during office hours. You are responsible for paying before your coaching session (Cash or EFT). Assessments are charged separately and fees will be discussed as necessary.
Banking details: Dr Nadine Dunn, FNB Saveways, Cheque Account, Account number: 624 850 855 78, Branch number: 27-04-50. Please use your name Name and Surname as reference.
If a speed point is used or a direct bank deposit is made, the cost of the transaction will be carried by you. This will be added onto your account for payment. Speed point cost is 3.6%.
I will provide you with an invoice only if you request one from me. You cannot submit this to your medical aid.
If you are unable to pay for a session, due to unforeseen financial constraints please discuss this with me beforehand in order to make an arrangement. Please note that it is my right to employ a Debt Collector at your cost if you do not pay for professional services provided.
It is my practice to charge for other professional services that you may require, such as report writing, telephone conversations, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request of me. For other fees and services please find attached a copy of my prices. Please note the time allocation and date allocation on the pricelist.
9. PAYMENT PLANNING
In order for us to set realistic goals and priorities, it is important to evaluate what resources you have available to pay for the coaching.
10. CONTACTING ME
My cellular phone is on silent during the day as I am working with clients. The quickest way to get hold of me is to phone and leave a message. Please include your name and surname in the message so I know who you are. I listen to my voice messages/read emails at the end of the day, and will try within reason to get back to you that day.
11. EMERGENCIES
If you feel you cannot wait for a return call/next coaching session or if you feel unable to keep yourself safe please go to your nearest local Hospital Emergency room/Out-patient section.
eMalahleni Private Hospital, Mandela Drive 39, Witbank, 1035, Telephone: 013 655 3000
12. OTHER RIGHTS
If you are unhappy with what is happening in coaching, I hope you will talk to me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another coach and you are free to end your coaching at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, or religion.
13. TERMS
Neither Dr. Dunn nor any of her employees or agents will be liable for any loss, theft or damage however caused whether as a result of my goods being left in and about the practice or the loss or damage to any motor vehicle. Dr. Dunn shall under no circumstances be liable for any damages or any losses as a result of any negligence whatever either as result of any coaching, administration, advice given or from any form coaching recommended to me or any of my dependents. I hereby indemnify and hold Dr. Dunn harmless against any such claims as may arise from here. This form contains all the terms and conditions, representations, guarantees and warranties between myself and Dr. Dunn and any amendment, cancellation or variation hereof shall only be effective once recorded in writing and signed by Dr. Dunn. No latitude or indulgence granted by Dr. Dunn shall be binding nor shall the same be deemed or construed to constitute a waiver or novation of Dr. Dunn’s rights. I waive the right to attach any condition of any nature whatsoever to any payment. If a condition is so attached then Dr. Dunn shall be entitled to accept payment as if no condition had been attached, especially if payment is purportedly made in full and final settlement. No person employed by Dr. Dunn will have any authority to vary, in any way, these terms unless so authorized in writing by Dr. Dunn. While fully understanding that Dr. Dunn will try her best to help me resolve my problem or symptoms, I fully understand that there is no guarantee that the coaching will be successful. I understand that the session might be fully audio-or videotaped or both at the discretion of Dr. Dunn and that these audio- or videotapes will be kept confidential by Dr. Dunn. I understand that memory is imperfect and research has shown that there is no guarantee that all the information revealed during or after is factually accurate. However, I understand that whatever information is revealed during the sessions will be used entirely and solely for the clients’ coaching benefit. If the outcome of the coaching is not what I expected it to be, I hereby agree that I will not have legal cause of action against Dr Dunn based on her professional and competent use of various coaching techniques. Permission is also granted by me that the information obtained during a consultation can be used for training, study purposes and publication by Dr. Dunn, with due regard to protecting the confidentiality of the client. I acknowledge that all coaching sessions scheduled outside office hours, i.e. before 08h00 and after 17h00 on weekdays, as well as all coaching sessions scheduled over weekends, will be deemed to be emergency consultations. As such, all emergency treatments will be subject the relevant consultation fee plus a 50% after hours fee. The coaching hour consists of fifty (50) minutes coaching time and the (10) minutes for administrative purposes. In the case of double coaching sessions, the coaching time will be one hundred (100) minutes and twenty (20) minutes for administrative purposes. I understand that at times coaching may leave me feeling out of sorts. If advised by Dr. Dunn or her staff not to drive immediately afterwards, I understand that any failure on my part to heed this advice, will result in me being fully responsible for my actions. Disclaimer: Dr. Dunn and her employees or agents do not accept or take any responsibility or liability for the safe custody of, or damages to any vehicle or articles therein, nor for any injuries or loss but not limited to any negligent act of her employees due to any collision, fire, theft, rain, hail, or any cause whatsoever. All vehicles are parked in all respects at the risk of the parker/owner thereof and all person entering these premises do so at their own risk. Right of admission reserved.
14. CONSENT
I knowledge and understand the benefits and risks as made known to me by Dr. Dunn and as reflected in this form, I hereby give consent to participate in counselling.