DR. BARRIE BIRGE
LSCW. C.HYP
INDIVIDUAL, COUPLE & FAMILY THERAPY
Masters in Clinical Social Work, Columbia University
Doctorate in Couples & Family Therapy, Antioch University New England
Individual, Couple & Family Coaching Agreement
INFORMED CONSENT FOR COACHING
Welcome. I'm honored you've chosen to begin this process. This agreement outlines how we'll work together, what you can expect from coaching, and the policies that help create a professional, respectful, and collaborative experience Please read it carefully, and let me know if you have any questions before signing.
This document contains important information about my coaching services, business policies, confidentiality, telehealth, and our coaching agreement. Please read it carefully before signing. We will review any questions you may have before we begin working together.
1. COACHING SERVICES
What coaching is:
Coaching is a collaborative process that supports you in clarifying goals, creating action steps, and achieving meaningful change.
How coaching differs
from psychotherapy:
Coaching does not provide mental health assessment or diagnosis; it does not delve into past trauma or psychodynamic issues; it is not a reimbursable healthcare treatment; it is not reimbursed by health insurers: and it is not subject to the same ethical obligations as mental health treatment, It tends to focus on the "here and now," on goal-setting, motivation, and accountability for personal change (Jackson, 2005).* (NASW.com)
Individual Coaching for Adults:
If engaged in individual coaching, the beginning of our together will involve establishing a relationship, assessing current needs, and then collaborating to build a coaching plan. Coaching sessions are typically scheduled for a 45-60-minute duration. You are able to stop working together at any point if you wish to do so.
Coaching for Minors:
Persons under the age of 18 and who are not emancipated are considered minors. Law allows parents/guardians to examine their child's records unless Barrie Birge decides that such access is likely to injure the child. Unless informed otherwise, I assume that every child has two parents with equal rights to initiate, and communicate with me. Support and engagement from parent(s)/ guardian(s) will increase the likelihood of positive outcomes.
Couple/Family Coaching Sessions:
Couple and family coaching is oriented towards the relationships within people's lives. While attention is paid to individual members, added emphasis is on the way individual behaviors affect relationships.
2. RECORDS & CONFIDENTIALITY
Records
According to the Health Care Act of 1992 you have a right to review a copy of your file. You also have the right to request that your coach provides a copy of your file to other health care providers with your written authorization.
The only portion of your record that I can provide, or share, is information that is generated here.
Confidentiality
Your file contains written information about our work together, including an initial assessment, progress notes, signed intormation information, documentation of communication, and summary information. You have the right to access and review your records upon request. Unless otherwise required by law, information revealed by you during coaching will be kept confidentell and will not be released to any other person or agency without your written permission, or in the case of a minor, the pormission of a parent or legal guardian. Current law requires information to be provided under the following circumstances: When abuse or neglect of a minor child or incapacitated adult is suspected, in which case the appropriate state authority must be informed.
FINANCIAL POLICIES
The client's charge will be established at the onset of coaching and will be understood as the Financial Agreement.
Payment is due at the time of service. Failure to pay fees/ balances can result in the termination of coaching. This agreement can be modified at any time with the mutua
consent of the client and me. I cannot quarantee the confidentiality of electronic communications. Protected health information will not be included in voicemails, emails,
or text messaging.
CANCELLATIONS
If you need to cancel an appointment please call or email the office at least 24 hours before your appointment. Clients failing to keep appointments, or not canceling at least 24 hours in advance of the appointment, will be charged
The full session fee.
TELEHEALTH CONSENT
Telehealth involves the use of electronic communications to hold live two-way audio/video sessions. The electronic systems utilized for communication include safety and security protocols that are HIPAA compliant and able to best protect the confidentiality of the audio/video session. Unless specific consent is obtained, the video platforms being utilized do not record sessions. Telehealth practices and policies can change per insurance and governmental policies. I reserve the right to alter this consent to abide with any new laws or regulations.