Consultation Agreement

MENTAL HEALTH, NUTRITION, AND CAREER ANALYSIS

INFORMATION DISCLOSURE STATEMENT

Most of the confidentiality verbiage in this document relates to holistic health; however, general confidentiality is conferred to all clients.

Analysis is a collaborative relationship that works in part because of clearly defined rights and responsibilities held by each person. This professional framework helps to create the safety necessary to take emotional risks and the support to become empowered to change. As a client, you have certain rights that are important for you to understand. There are also certain limitations to those rights of which you should be aware. As a Holistic Health Educator, I have corresponding responsibilities to you.

My Responsibilities to You as Your Holistic Health Educator

I. Confidentiality

With the exception of certain specifics described below, you have the absolute right to the confidentiality of your session. I cannot and will not tell anyone else what you have told me, or even that you are in session with me without your prior written permission. I will always act so as to protect your privacy even if you do release to me in writing to share information about you. You may direct me to share information with whomever you choose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend a session with you.

For health-related services, you are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law ensures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you electronically (for example, sending bills or emailing information), it will be done with special safeguards to ensure confidentiality.

If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential. All emails are retained in the logs of your or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you, and any responses that I send to you, will be electronically saved and stored as a part of your treatment record.

The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect:

1. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.

2. If I have good reason to believe that you are abusing or neglecting a vulnerable adult or child, or if you give me information about someone else who is doing this, I must inform law enforcement and Child Protective Services (CPS), respectively and immediately. If you are between the ages of 16 and 18 and you tell me that you are having sex with someone more than five years old than you, or sex with a teacher or a coach, I must also report this to CPS, even though at age 16 you have the right to consent to sex with someone no more than five years older than you. I would inform you before I took this action.

3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or the county crisis team. I am not obligated to do this and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.

The next is not a legal exception to your confidentiality. However, it is a policy you should be aware of if you are in couples therapy with me.

If you and your romantic partner decide to have individual sessions as part of the couples therapy, what you say in those individual sessions will be considered to be a part of the couples therapy and can and probably will be discussed in our joint sessions. Do not tell me anything you wish kept secret from your partner. I will remind you of this policy before beginning such individual sessions.

II. Record-keeping.

I keep very brief records, noting only that you have been here, what interventions happened in session, and the topics we discussed. If you prefer that I keep no records, you must give me a written request to this effect for your file and I will only note that you attended therapy in the record. Under the provisions of the Health Care Information Act of 1992, you have the right to a copy of your file at any time. You have the right to request that I correct any errors in your file. You have the right to request that I make a copy of your file available to any other health care provider at your written request. I maintain your records in a secure location that cannot be accessed by anyone else.

III. Diagnosis

I do not diagnose or use the DSM-V. I find that most mental health challenges are on a codependency spectrum. My therapeutic measures relate to self-image, life, and relationship management. I find that mental health professionals who use the DSM-V oftentimes misdiagnose. Misdiagnosis has long-term consequences that can adversely affect the client’s life goals (e.g. self-esteem, relationships, career). My therapeutic goal is to empower clients so that they can achieve their full potential. If I believe your challenges are beyond the scope of my services, I will refer you to a specialized mental health specialist.

IV. Other Rights

You have the right to ask questions about anything that happens in therapy. I’m always willing to discuss how and why I’ve decided to do what I’m doing, and to look at alternatives that might work better. Please feel free to ask me to try something that you think will be helpful. You can ask me about my training, and you are free to discontinue therapy at any time.

My Training and Approach to Therapy

I earned a master’s in forensic psychology and 64 additional continuing education credit hours in Marriage and Family Therapy. Specialized courses I have taken are in Substance Abuse • Personality Theory • Human Development • Sexuality and Gender Identity • Diversity & Inclusion • Family Systems • Maladaptive Behavior • Crisis Negotiation • Criminality, Law, and Ethics. I have experience counseling juvenile gang members, veterans, individuals, couples, and families. The foundation for my approach is a form of Cognitive Behavioral Therapy, called Rational Emotive Behavioral Therapy (REBT). I also incorporate Personality Theory, Family Systems Theory, and Transactional Analysis Theory. I am also an AFPA Certified Holistic Nutritionist. My goal is to heal both the body and the mind, but we will focus on your specific goals as you define them.

Coaching Techniques

I use a variety of techniques in therapy that are tailored for your specific needs. These techniques are likely to include, but not limited to, dialogue, motivational interviewing, interpretation, cognitive reframing, awareness exercises, self-monitoring experiments, visualization, journal-keeping, personality/skills tests, and reading.

Associated Risks

Holistic health coaching has potential emotional risks. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have. You may find your therapeutic relationship with me to be a source of strong feelings, some of them painful at times. It is important that you consider carefully whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful.

You normally will be the one who decides therapy will end, with three exceptions. First, if we have contracted for a specific short-term piece of work, we will finish therapy at the end of that contract. Second, if I am not — in my judgment — able to help you, because of the kind of challenge you have or because my training and skills are in my judgment not appropriate, I will inform you of this fact and refer you to another therapist who may meet your needs. Third, if you do violence to, threaten (verbally or physically), harass me, or any of my staff/family/associates, then I reserve the right to terminate you (unilaterally and immediately) from treatment. If I terminate you from therapy, I will offer you referrals to other sources of care, but I cannot guarantee that they will accept you for therapy.

Provider-Client Boundary

I answer e-mails and text messages for business purposes (i.e. rescheduling/canceling appointments). Conversations are restricted to scheduled appointment times unless otherwise noted in the contract agreement. If you send emails, I will assume that you intend to discuss them at a future session.

I will tell you in-advance of any anticipated lengthy absences and give you the name and phone number of the therapist who will be covering my practice during my absence. If you are experiencing an emergency outside of appointment times, then please call 911, or go to the nearest hospital emergency room for assistance.

Your Responsibility as a Client

You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 60 minutes. If you are late, we will end on time. If you no-show for two sessions in a row and do not respond to my attempts to reschedule, I will assume that you have dropped out of service and will make the space available to another individual, and you will pay for your missed sessions.

You are responsible for paying for your sessions upfront unless we have made other firm arrangements, in advance. My fee for a 60-minute session is $100.00 (unless a specific package is purchased with alternate fee schedules — check available packages for pricing here). If we decide to meet for a longer session, I will bill you prorated on the hourly fee. You may cancel your appointment for a refund with a 24-hour advance notice of intent to cancel session.

Any time I spend on the phone or responding to your e-mails/text messages (related to coaching) will be added at a prorated amount to your next session (unless it is a part of the purchased package), except for when I send you information necessary to the therapeutic arrangement (e.g. tests, contracts, follow-up self-help assignments). So, if you communicate outside the agreed upon package, then just know that an additional $15 is charged for each additional communication you send me expecting a response from me. If pro-rated amounts for extended session are not paid, then future sessions may be refused.

I am not willing to have clients run a bill with me. I do not accept barter for therapy. I do not accept Medicare/Medicaid, or insurance. I do accept debit/credit cards, Venmo, and Zelle.

Payment must be rendered at the time appointment is made or appointment will be cancelled. After payment is made, this confidentiality form must be signed and email-returned to hb@newzenvigor.com. If the signed form is not returned within 24 hours of the selected appointment, then the appointment will be cancelled, and payment will be refunded; however, future appointment opportunities will be rescinded.

If you agree to these terms, I will email or text you this form to capture your e-signature.

Client Signature ______________________________

Date ___________________________

Counselor Signature ______________________________

Date ___________________________