Informed Consent for Wellness Coaching

Welcome to Lock and Key Wellness, LLC (LKW). LKW provides confidential services for individual, couples, group, and family wellness coaching. This document contains important information about our 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 client rights regarding the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.

When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.

Wellness coaching is an alliance between client and coach to increase understanding and bring about change. The coaching process varies depending on the personalities of the coach and client and the particular problems you are experiencing. There are many different methods LKW may use to deal with the problems that you hope to address. Wellness coaching calls for a very active effort on your part. In order for the coaching to be most successful, you will need to work on the things we talk about both during our sessions and independently.

Wellness coaching can have benefits and risks. Since coaching often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, frustration, loneliness, difficulty concentrating, and helplessness. On the other hand, wellness coaching has also been shown to have many benefits, including the goal to seek joy in your daily life. Wellness coaching often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Although there are no guarantees of what you will experience, I will devote my attention to ensuring that we maintain a safe and respectful environment that can maximize the possibilities for you to achieve positive growth and healing.

Our first few sessions will involve an evaluation of your needs, goals, and circumstances. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow if you decide to continue with wellness coaching. You should evaluate this information along with your own opinions of whether you feel comfortable working with me.

If wellness coaching is begun, sessions will be scheduled at a frequency that is mutually agreed upon. We may also decide to change the frequency of sessions at any time during the course of your coaching. Once an appointment is scheduled, you will be expected to pay for the full fee unless you provide 24-hours (1-day) advance notice of cancellation. I understand illnesses, accidents, and other beyond-our-control situations occur, and with these events, there will be no charge as long as you contact the office of such an issue. If you appear in a session under the influence of alcohol or other substances, I will cancel the session, find you a safe ride home if needed, and require you to pay for the session.

In general, the privacy of all communications between a client and wellness coach are protected by law; we can only release information about our work to others with your written consent. There are a few exceptions to the confidentiality laws and standards, as follows:

• If your wellness coach believes that you or someone else is in clear and imminent danger of harm, your coach is legally obligated to inform proper authorities and others in order to help prevent the harm from occurring.
• If you provide information indicating that someone is being abused, your coach is legally obligated to notify proper authorities.
• In rare cases a court may order your coach to disclose information about you.
• If you are under 18 years old, your parents or legal guardian may have access to your treatment records.
• Our professional team meets regularly to provide peer consultation and improve quality of care.
• If a collection agency becomes necessary due to nonpayment.

It is also possible that at some point in the future you will be required by an outside agency to sign a release allowing the agency to review your treatment records. This may occur, for example, if you apply for life insurance, licensure or certification in some professions, or if you require a security clearance.

Records of any services you receive at Lock and Key Wellness, LLC are maintained in password-protected computer files and in paper files locked within filing cabinets in a locked records room. Access to these files is limited to this professional and administrative staff. Any request to release your records to outside agencies, insurance companies, etc. extends beyond Lock and Key Wellness, LLC's ability to protect confidentiality.

In an effort to provide you with the best possible service, your wellness coach may choose to consult with other professional staff or colleagues that are subject to the same confidentiality constraints that your coach is.

Research indicates that most people who engage in wellness coaching benefit from the experience; even so, it is possible for things to get worse before they get better. For example, it isn't uncommon for clients to make changes in their interpersonal relationships as a result of wellness coaching, and such changes can sometimes be difficult. In addition, some clients who work on especially troubling issues may find it difficult to concentrate. You and your coach will work together to determine the pace and form of treatment so as to minimize the risks while maximizing the benefits of wellness coaching.

Missed appointments: please give us as much notice as possible if you have to miss an appointment. Should you miss an appointment without calling 24 hours in advance, the regular hourly fee will still be charged.

Billing and payments. Payment is expected prior to each session and is nonrefundable.

Technology and social networking.LKW advises clients that use of email or text messaging has a number of risks and LKW cannot guarantee confidentiality of this type of communication. Therefore, the client should not use email or text for communication regarding sensitive medical or mental health information. LKW provides a professional website and newsletter with resources about wellness but does not accept “friend requests” from current or former clients on social networking sites. For the same reason, LKW requests that clients do not communicate with LKW via any interactive or social networking sites.

Hours of operation. You may contact your counselor between 9am and 5pm Monday through Friday (excluding holidays) by calling (656) 227-9547. If it is an emergency, you should go to the local emergency room.