Welcome to Holly Street Counseling therapeutic services. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
LIFE COACHING SERVICES
Life 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 life coaching, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your life coach have corresponding responsibility. Please be aware that therapy and life coaching are two different services. Psychotherapy services are more intensive than life coaching services. Life coaching assists individuals with finding ways to navigate through life while addressing specific goals.
Life 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 may requires discussing the unpleasant aspects of your life and pushing you to do things you are not used to doing. However, life coaching has been shown to have benefits for individuals who undertake it. Life coaching can lead 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. But, there are no guarantees about what will happen
Appointments will ordinarily be 45 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 48 hours notice. If you miss a session without canceling, or cancel with less than 48 hour notice, my policy is to collect a fee of $25 prior to the next session (unless we both agree that you were unable to attend due to circumstances beyond your control) If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.
Session fees are as follows:
1. One 45 minute session =$65
2. Four 45 minute sessions=$180
All sessions are paid for via IVY PAY. All sessions are provided via the Zoom App. This is a free app that can be downloaded on most smartphones.
I do not accept insurance plans as a method of payment.
I do keep appropriate records of the life coaching that I provide. Your records are maintained in a secure location in an office. I keep brief records noting that you were here, your reasons for seeking life coaching, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional , which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.
Holly Street Counseling therapeutic services’ policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.
I am not available by telephone., but can be reached by email. I will respond within 48 hours of receipt of the email. If for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences.
If you are unhappy with what is happening in coaching, I hope you will talk with 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 therapist and are free to end 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, religion, national origin, or source of payment. You have the right to ask questions about any aspects of coaching and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.
CONSENT TO LIFE COACHING
Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.
Once services have been paid for and an appointment has been scheduled, there will be no refunds regardless if services are rendered or not.