Alpine Connection Life Coaching

Consent form for clients over the age of 18

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Alpine Connection Life Coaching

Christian T. Hill, MA

Informed Consent

430 Beacon Lite Road, #140 Monument, CO 80132 (719) 233-TEEN (8336)

Agreement to Life Coaching:
 

1. Client acknowledges 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 the Client’s exclusive responsibility to seek such independent professional guidance as needed. If Client is currently under the care of a mental health professional, it is recommended that the Client promptly inform the mental health care provider of the nature and extent of the coaching relationship agreed upon by the Client and the Coach.
 

2. Life coaching is not currently a regulated industry in the state of Colorado or Texas. It will be solely the responsibility of the client to determine the effectiveness of the services rendered and the competency of the coach.

3. Life coaching assumes the mental health of the client. Life coaching is a collaborative process that is present and future oriented. It is action oriented, solution focused and encourages change. It involves
accountability and commitment to growth through increased competence, commitment, and confidence.


4. As the client, you set the agenda for these sessions and your success will largely depend upon your willingness to define goals and try new approaches. You can expect me, as your life coach, to be honest and direct, asking straightforward questions and offering challenging techniques to help you keep moving forward. 

 Financial arrangements

 

The pricing of Alpine Connection Life Coaching and Christian T. Hill, MA is based off a level of experience, expertise, and involvement in finding solutions for you and your family that go beyond the traditional 1 hour therapy model.

 

Christian sees a limited number clients and offers a level of a care that is relational yet assertive in finding a successful treatment plan that helps families navigate a very challenging process but which intentionally becomes more affordable over time. As the client improves there are lower price points for the client to stay involved if further care is needed although the ultimate goal is to empower a client to be fully independent through the coaching process.
 

Cancellation – you must cancel your appointment 24 hours prior or you will be charged the full amount.

 The agreed cost for life coaching will be $165.00 per session which will last for 50 minutes (an additional 10 minutes will be spent on therapy notes, referrals, and assessments), or $95 for a 30 minute session.

I understand that if total payment is not received within a 30 days, that I the client am responsible not only for the outstanding balance due, but additionally any costs incurred to Alpine Connection Counseling from collection fees and all legal fees.  I understand that Alpine Connection Counseling does not accept insurance and that reimbursement is to be handled between the client and their own insurance company.
 

WAIVER AND RELEASE
 

By signing below, I assume any risk and take full responsibility and waive any claims related to any personal injury, of myself or others death or damage to personal property arising from Alpine Connection Life Coaching activities and events organized by Alpine Connection Life Coaching. I understand and confirm that by signing this WAIVER AND RELEASE I have given up considerable future legal rights. I have signed this Agreement freely, voluntarily, under no duress. My signature is proof of my intention to execute a complete and unconditional WAIVER AND RELEASE of all liability to the full extent of the law for the benefit of Alpine Connection Life Coaching, its employees, members, managers, and agents. I am 18 years of age or older and mentally competent to sign this waiver and release or I have full guardianship to consent to this waiver and release on behalf of the child named below.

Consent for telehealth, phone, and or virtual

By sigining and submitting this document, I hereby consent to engage in
virtual coaching with Christian T. Hill, MA. I understand that virtual coaching includes consultation, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications. I understand that virtual coaching also involves the communication of my medical/mental information, both orally and visually.


I understand that I have the following rights with respect to virtual coaching:


1. I have the right to withhold or withdraw consent at any time without affecting myright to future care.
2. I understand that the information disclosed by me during the course of my coaching or consultation is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality as it relates to immenent harm to self or others.
3. I understand that there are risks and consequences from virtual coaching, including, but not limited to, the possibility, despite reasonable efforts on the part of Mr. Hill, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
4. In addition, I understand that virtual coaching based services and care may not be as complete as face- to-face services. I also understand that if Mr. Hill believes I would be better served by another form of therapeutic services (e.g. face-to-face services) I will be referred to a professional who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of consultation, and that despite my efforts and the efforts of my coach, my condition may not be improve, and in some cases may even get worse.
5. I understand that I may benefit from virtual coaching, but that results cannot be guaranteed or assured.
6. I accept that virtual coaching does not provide emergency services. During our first session, Mr. Hill and I will discuss an emergency response plan. If I am
experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support.
7. I understand that I am responsible for (1) providing the necessary computer,
telecommunications equipment and internet access for my teletherapy sessions, (2) the information security on my computer, and (3) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my virtual coaching session.
8. I understand that while email may be used to communicate with Mr. Hill,
confidentiality of emails cannot be guarranteed.
9. I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law.

 

 

I have read and understand my rights as a client and by signing below I am verifying my consent to coaching with Christian T. Hill, MA and Alpine Connection Life Coaching

Your Signature

Alpine Teen Counseling Center