COUNSELING AND EMDR THERAPY

Creating Your Balance LLC

Informed Consent for Coaching, Psychoeducation and Consultation Services

General Information

The coaching relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

Coaching Process

The outcome of our work together will depend largely on your willingness to engage in the coaching process which may, at times, result in uncomfortable emotions. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and help you clarify what it is that you want for yourself. I will do my best to help you clarify what it is that you want for yourself in the face of your circumstances and habits and facilitate you reaching those goals and aspirations. 

Confidentiality

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

If we see each other accidentally outside of the coaching / therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the office.

Upon termination of services by you, or the therapist, or thirty (30) days following your last attended session, you will be considered an inactive client and no longer receiving services from Creating Your Balance LLC, its employees or independent contractors.

Required Disclosure

It is important to note that while Athena McKee is a Licensed Associate Counselor in the state of Arizona, she will not be offering you counseling services. Relational or personal coaching is different from counseling in that it requires a level of capacity in the client. While effective coaching sometimes addresses family of origin patterns and history, it does so with an aim to uncover capacity and potential within the client with a forward focus on the client living up to their relational and personal potential. 

Athena McKee (heretofore referred to as “Coach”) is not a licensed physician, psychologist or other provider of medical or psychological services in your state, unless you reside in Arizona. Although Coach is a licensed associate counselor in Arizona, Coach is not functioning in the role of a licensed therapist during these coaching sessions, but rather, using her training to inform the activities.

Nature of Services

Coach will offer the following services: guiding clients to make thoughtful, manageable lifestyle adjustments to improve overall well-being and vitality. In addition, coaching involves attuning the client to their own goals, relationships, and habits, so clients can release limiting beliefs, clarify their values, and achieve overall self and relational improvement.

1. No Therapy: Most states do not prohibit individuals from offering coaching or mentorship services. However, states require a license in their state to practice medicine and therapy to undertake the diagnosis, prevention, treatment, or cure of any disease, pain, deformity, injury, or physical or mental condition and require a license to state that any product or service might cure any disease, disorder, or condition. Thus, in the role of coach, Coach does not offer therapy, or therapeutic diagnoses.

2. No Guarantee: I recognize that Coach cannot guarantee results or any specific outcomes from our work together. I am solely responsible for any action taken based on my interpretation of any information presented.

3. Right to Discontinue Services: I understand that Coach has the right to refuse to continue delivering services at any time for any reason whatsoever and will refund the client’s advance payment for the portion of unused services.

4. No Medical or Psychological Services: I am not engaging Coach for any medical or psychological services. I understand that Coach does not diagnose, treat, or claim to do any medical or psychological treatment, and that Coach’s services are not designed to replace conventional treatment methods of medical or psychological conditions. I also understand that Coach does not offer therapy for emotional or mental disorders. I am responsible for my own health care decision-making by obtaining any necessary consultations with appropriately licensed health care professionals such as physicians and psychologists. In case of an emergency, I will call 911 and in case of need for medical or psychological assistance I will contact my appropriate medical or licensed mental health care provider.

5. My Responsibility for My Self-Care: I understand that any relational or inner-directed work, or self-reflection can bring up distressing feelings, images, thoughts and behaviors. I agree to seek medical assistance or psychotherapy or any other appropriate physical or mental diagnosis and treatment from a practitioner duly licensed in my state of residence (such as a licensed medical doctor or licensed psychologist) if I find that these distressing aspects create a danger for myself or for others.

6. No Mental Illness: I acknowledge that I have not been hospitalized for any psychiatric condition within the last ten (10) years, nor have charges been brought against me based on my behavior.

7. Assumption of Risk: I knowingly, voluntarily, and intelligently decide to receive the services described above, and I knowingly, voluntarily, and intelligently assume all risks involved in the same. As a result of my assumption of these risks, I agree to release, hold harmless, indemnify, and defend Coach and her agents from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the services described above, or arising out of or in connection with referral to other practitioners or merchants for delivery of any services.

8. Cancellation: I understand there is a 24-hour appointment cancellation policy and that if I miss my scheduled appointment or cancel within less than 24-hour notice, I am responsible for the full cost of the session.

9. Financial Responsibility: I understand that Coach does not accept insurance or negotiate with insurers, and that Coach’s services are likely not reimbursed by any insurer. I am financially responsible for my session and agree to pay the charges incurred.

10. Telecommunication Used; Electronic Communication: Coach may provide services via phone. Benefits include easier access to communication and convenience; risks include technology failure, interruptions, poor connection. While Coach will work to maintain confidentiality, Coach cannot ensure or guarantee the confidentiality of any communication through electronic media, including email and text messages, even if I transmit sensitive information through such media.

11. Social Media: I understand that to maintain confidentiality, Coach typically does not accept “friend” or contact requests via social media to a personal account only to professional accounts.

Consent for Telehealth Consultation and Sessions

1. Coach explained to me how the phone technology that will be used to conduct such a visit will not be the same as a direct client / coach visit, due to the fact that I / we will not be in the same room as the Coach.

2. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that either the Coach or I / we can discontinue the telehealth visit if it is felt that the phone connections are not adequate for the situation.

3. I have had a direct conversation with Coach, during which I had the opportunity to ask questions in regard to this.

In Case of Emergencies

Before each session begins the provider will request the address for which you are currently located and will use this information to give to authorities in case of a crisis or emergency. If for some reason you and the provider get disconnected and you are in a crisis/emergency, you agree to call 911, go to your local emergency room immediately or contact the National Suicide Hotline at 9-8-8. If the provider has concerns about your safety including you being a danger to yourself or others at ANYTIME during a session, the provider will call 911.

Consent to Treatment

I, the undersigned, have read this form in its entirety and agree to all of the stipulations set forth herein.