Coaching relationships are highly personal but are also a contractual agreement. This consent will help provide a clear framework in your relationship. Understanding how the relationship works and expectations can be discussed with your clinician at any time.

True North Men's Coaching may include members of a clinical team and as a result information may be shared with other team members for purposes of clinical supervision and/or to enhance the quality of client care. If a conflict of interest between a dinician and client is identified, alternate arrangements will be made. Information shared in sessions with the coach is confidential and shared with others outside of the True North Men's Coaching only if/when consent is provided. However, in law there are circumstances where disclosure of personal information is required without the client's consent.

These circumstances where disclosure is required without consent are:

1. In the case of suspected or reported child abuse (Child and Family Services Act).
2. When a client informs the Coach of abuse from a regulated health professional, the appropriate College Will be notified
3. When based on reasonable grounds, disclosure is necessary to reduce or eliminate the risk of harm to self or others (e.g. suicide, homicide, child abuse).
4. When necessary for legal proceedings (e.g. file is subpoenaed by the court).
5. To facilitate an investigation if authorized by warrant or any provincial or federal law
6. To contact a relative, friend or substitute decision maker when the client is unable to do so (e.g. injured or incapacitated).

I hereby request the services of True North Men's Coaching and do voluntarily consent to participate, to the best of my ability, in agreed treatment recommendations.

In addition, I fully understand and agree with the following:

1. My personal health information will be kept in complete confidence unless I have provided written consent to share this information. I can revoke my written consent at any time.
2. I will not attend a treatment session while under the influence of any substance that impairs my ability to participate fully (alcohol, street drugs, non-prescribed medications, etc.).
3. I have the right to actively participate in the formulation of any treatment plans and its implementation and to be informed of any changes in my treatment plan and the ability to end treatment at any point that I feel necessary.

I understand that personal coaching is not therapy, counseling, psychotherapy, or a substitute for mental health treatment. Coaching is a collaborative, goal-oriented process focused on personal development, self-reflection, and skill building. It does not involve the diagnosis or treatment of mental health conditions.

I acknowledge that I am fully responsible for my own decisions, actions, and outcomes, both during and after coaching sessions. While the coach may offer perspectives, information, tools, or guidance, I understand that all choices and actions taken as a result of coaching remain my sole responsibility.

I understand that coaching involves exploration, challenge, and personal effort, and that results cannot be guaranteed. Progress depends on my participation, honesty, and willingness to engage in the process.

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If I am experiencing significant emotional distress, mental health symptoms, or thoughts of self-harm, I understand that it is
my responsibility to seek appropriate professional or emergency support, and that coaching is not intended to replace such
services.

Please note: We are not a crisis center, please call the crisis line if you are in crisis or visit your local emergency department.
Telecare Distress Line of Greater Simcoe: 1-705-325-9534, Crisis Services Canada 1-833-455-4555 or text 45545

Online individual and group sessions are currently being offered using the provider "Sessions" (Psychology Today) and
"zoom.us" to provide video conferencing. These forums take reasonable steps to protect individuals' privacy, but it is important
to acknowledge that all online options have some risk such as personal data collection, personal data stored outside of Canada,
and confidentiality breaches. Signing into sessions from an email account rather than from a Facebook account could decrease
these potential risks. You can help to minimize the risk of breaches in confidentiality by ensuring that you are in a setting that
allows privacy. Your screen should not be visible to others and others should be unable to hear the conversation.

Having your computer password protected and utilizing up-to-date firewalls as well as utilizing up to date antivirus software,
can also be helpful at preventing the unwanted sharing of information.

I understand that there are some risks associated with online counseling with regards to confidentiality. Should I choose
to pursue therapy using video conferencing, I accept these risks.

For clients participating in Couples/Group Coaching, confidentiality will be stressed to all group members; however, True
North Men's Coaching cannot guarantee that all group members will keep what is said confidential. Participants should
consider this when choosing to disclose, and if disclosing, to disclose gradually in the process in order to evaluate their level of
comfort, ongoing.

I understand that all sections within this Informed Consent to Treatment agreement are also applicable to participating in
Couples/Group Coaching. In addition, I understand that confidentiality by group members cannot be guaranteed. Should
I choose to participate in Couples/Group Coaching, I accept these risks.

Effective January 1, 2004, the government implemented the Personal Information Protection and Electronic Documents Act
(PIPEDA). Our office privacy policies regarding this act are listed on this form.

Regarding this policy, we would like your informed consent. This means that we want you to understand what we do with the
information collected about you. We ensure that only necessary information is collected about you and we only share your
information with your consent (with the exceptions noted above). The collection, storage, retention and destruction of your
personal information complies with existing professional legislations and privacy protocols.

Our office understands the importance of protecting your personal information. To help you understand how we are doing that,
we have outlined how our office is using and disclosing your information. This office will collect, use and disclose
information about you for the following purposes:

• to assess your needs
• to deliver safe and effective client care.
• to provide care
• to enable us to contact you
• to establish and maintain communication with you
• To notify your emergency contact if we believe your life or
  security is at risk.

• to communicate with members of the clinical team
• to allow us to efficiently follow up for treatment, care and billing
• to process E-transfers, debit and payments to assist
• this office to comply with all regulatory
  requirements
• to ensure general compliance with the law

Phone: 705-702-5421 - Email: mike@truenorthmenscoaching.ca

I understand that to provide me with healthcare, True North Men's Coaching will collect some personal information about me, i.e. home, work phone numbers, address, healthcare information, etc. I understand this privacy policy about the collection, use and disclosure of personal information, steps taken to protect information, and my right to review my personal information. I understand how the privacy policy applies to me.

I agree to True North Men's Coaching, namely my coach, collecting, using and disclosing personal information about me as set out above in both physical and electronic formats.

Please do not assume that you have coverage without inquiring. Most Insurance providers do not cover coaching.

I understand that I am responsible for my payment to True North Men's Coaching, regardless of the outcome of my insurance claim.

We utilize a cancellation policy to ensure there is a high level of commitment to coaching practice from our clients. Please understand that missing scheduled appointments can hinder your treatment plan.

• Cancellations with more than 48 hours notice will not be billed.
• Cancellations with less than 48 but more than 24 hours will be billed at 50% of your scheduled rate.
• Cancellations or No Show's with less than 24 hours notice will be billed at 100% of your scheduled rate.

We fully understand that some instances cannot be avoided, and we will work with individuals to offer a phone session in place of a face-to-face meeting at the scheduled time. There are no exceptions to this policy.

I understand the cancellation policy.

Payments are to be made on the session date.
Forms of payment accepted are: E-transfer, cash, or Paypal.

We understand that privacy and confidentiality is important. If seen outside the office the coach will not acknowledge you first. If you wish to acknowledge first, then coach will engage in conversation.
Also please note that coach generally do not accept social media friend requests to their personal accounts in order to honour the confidential relationship.

I understand and agree to the information and declarations contained within this True North Men's Coaching Informed Consent to Treatment.

Please save the completed form on your device and email a copy to: mike@truenorthmenscoaching.ca

Phone: 705-702-5421 - Email: mike@truenorthmenscoaching.ca