disclosure form

PLEASE COMPLETE THIS DISCLOSURE FORM
BEFORE YOUR NEXT SESSION. 

CLIENT INFORMATION

EMERGENCY CONTACT INFORMATION

DISCLOSURE STATEMENT

I acknowledge that coaching does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association and that coaching is not to be used as a substitute for counseling, psychotherapy, psychoanalysis, mental health care, substance abuse treatment, or other professional advice by legal, medical or other qualified professionals and that it is my exclusive responsibility to seek such independent professional guidance as needed. If I am currently under the care of a mental health professional, it is recommended that I promptly inform the mental health care provider of the nature and extent of the coaching relationship agreed upon by me and the Coach.

 

I understand that I am financially responsible for all charges or services provided to me. I realize that if I do not give one full business day notice prior to cancellation of appointment, I will be fully charged for this appointment in full. The ongoing fee for services is $75.00 per session. Your credit card statement will read “FIRE FORGED COACHING”.

I acknowledge that I may terminate or discontinue the coaching relationship at any time.

I acknowledge that the Coach may terminate or discontinue the coaching relationship at any time.

I understand that no paid materials are required for recovery coaching. If I elect to purchase any materials, I do so without influence or coercion from my coach.

Also, no statements will be provided for insurance and no insurance billing will be provided.

If I am involved in a divorce or custody litigation, I understand that the role of a coach is not to make recommendations for the court concerning custody or parenting issues or to testify in court concerning opinions on issues involved in the litigation. By signing this disclosure statement, I agree not to call the coach as a witness in any such litigation. Only court-appointed experts, investigators, or evaluators can make recommendations.

CLIENT RECORD RETENTION POLICY

Records regarding the coaching of adults will be kept for 7 years after coaching ends or following our last session, but may not be retained after 7 years. Records for coaching of minors will be kept for 7 years, beginning on the last date of coaching or for 7 years beginning on the date when the minor turns 18 years of age, whichever is later. In no event are records required to be kept longer than 12 years.

CONFIDENTIALITY

This coaching relationship, as well as all information (documented or verbal) that I share with the Coach as part of this relationship, is bound by the principles of confidentiality set forth in the ICF Code of Ethics. However, I am aware that the Coach-Client 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. The Coach agrees not to disclose any information pertaining to the me without my written consent. The Coach will not disclose the my name as a reference without my consent. There are exceptions which include:1) If the Coach is required to report suspected child abuse or neglect to the appropriate law enforcement agency; 2) If the Coach receives information from me concerning a serious threat in imminent physical violence against a specific person,

the Coach must inform that person of the threat, and also notify law enforcement authorities; and 3) The Coach is required to report any suspected threat to national security to federal officials.

Under Colorado Law, CRS 14-10-123.8, parents have the right to access mental health treatment information concerning their minor children, unless the court has restricted access to such information. If I request information from my Coach, I may be provided with a coaching summary.

I understand that in some circumstances my case may be discussed with other professionals, who provide services within the center, in order to provide the best coaching experience for me.

I agree not to record our sessions without the Coach’s written consent; and the Coach agrees not to tape record a session or a conversation with me without my written consent.

INFORMED CONSENT FOR COACHING

I have read this Disclosure Statement, understand the disclosures that have been made, and acknowledge that a copy of it has been provided to me.

I hereby provide consent for treatment of the following clients: 

Thanks for submitting!