LDS Hope and Recovery Client Consent Form

Welcome to LDS Hope and Recovery. This Agreement and Consent Form for online professional coaching is being provided to you (client) in order to inform you about online coaching and answer some questions you may have. 

As a client of LDS Hope and Recovery I understand that online work is technical in nature and that there may be problems with Internet connectivity, which is the fault of neither the online coach, LDS Hope and Recovery nor me. Internet availability may be limited or disrupted by things such as server maintenance, upgrades, or other problems (such as software or hardware malfunction) or natural or man-made disasters (such as terrorist acts, Internet viruses, and so forth). These types of problems are beyond the control of LDS Hope and Recovery and me (client). If something like this were to occur, any scheduled appointments would be re-scheduled by your coach at no additional cost to you (client).

I understand that I must be at least 18 years of age to consent for online coaching by LDS Hope and Recovery. (If not at least 18 years old, a parent or legal guardian must contact LDS Hope and Recovery and provide a written consent for services). As a client of LDS Hope and Recovery, I declare that I am free of suicidal thoughts. I also understand that LDS Hope and Recovery may be required to violate confidentiality to make appropriate legal notifications if your online coach reasonably believes I am involved in child abuse or neglect, if I intend to harm myself, or if I am involved in criminal activity.

I realize that I will be charged per a pre-arranged price that LDS Hope and Recovery and yourself agree upon. We need to recognize that during the process of working on these difficult issues, discomfort may arise (as difficult issues are addressed and worked through). This is an often times necessary part of coaching, even though it does not guarantee resolution of any kind or assure success for coaching, either explicit or implied. This means that there is no guarantee as to the outcome from the services of or LDS Hope and Recovery. This includes limitation or restriction, of any guarantee, for information, online coaching, uninterrupted access, and other services provided through or LDS Hope and Recovery.

In addition, as a client of LDS Hope and Recovery, I can end services at any time, for any reason, without prior notification or explanation to LDS Hope and Recovery. (Although a note explaining any decision to stop services would be greatly appreciated). 

Lastly, although LDS Hope and Recovery has taken a significant number of steps to ensure the confidentiality and privacy of Online communication(s) between you and your online coach, these actions, in whole or in part, cannot guarantee the security of Internet transmissions. I permanently agree to release and indemnify LDS Hope and Recovery from all suits, claims, and other actions originating from coaching provided through LDS Hope and Recovery.

 

Online Disclaimer: Welcome to LDS Hope and Recovery. This Agreement and Consent Form for online counseling is being provided to you (client) in order to inform you about Online Therapy and answer some questions you may have. As a client of LDS Hope and Recovery I understand that Online Therapy is technical in nature and that there may be problems with Internet connectivity, which is the fault of neither the online counselor at LDS Hope and Recovery nor me. Internet availability may be limited or disrupted by things such as server maintenance, upgrades, or other problems (such as software or hardware malfunction) or natural or man-made disasters (such as terrorist acts, Internet viruses, and so forth). These types of problems are beyond the control of LDS Hope and Recovery and me (client). If something like this were to occur, any scheduled appointments would be re-scheduled by your online therapist at no additional cost to you (client).

I understand that I must be at least 18 years of age to consent for online counseling by LDS Hope and Recovery. (If not at least 18 years old, a parent or legal guardian must contact LDS Hope and Recovery and provide a written consent for services). As a client of LDS Hope and Recovery, I declare that I am free of suicidal thoughts. I also understand that LDS Hope and Recovery may be required to violate confidentiality to make appropriate legal notifications if your online therapist reasonably believes I am involved in child abuse or neglect, if I intend to harm myself, or if I am involved in criminal activity.

I realize that I will be charged per a pre-arranged price that LDS Hope and Recovery and yourself agree upon. We need to recognize that during the process of online counseling psychotherapy, discomfort may arise (as difficult issues are addressed and worked through). This is an often times necessary part of online therapy, even though it does not guarantee resolution of any kind or assure success for online counseling, either explicit or implied. This means that there is no guarantee as to the outcome from the services of or LDS Hope and Recovery. This includes limitation or restriction, of any guarantee, for information, online counseling, uninterrupted access, and other services provided through or LDS Hope and Recovery.

In addition, as a client of LDS Hope and Recovery, I can end services at any time, for any reason, without prior notification or explanation to LDS Hope and Recovery. (Although a note explaining any decision to stop services would be greatly appreciated). Lastly, although LDS Hope and Recovery has taken a significant number of steps to ensure the confidentiality and privacy of Online communication(s) between you and your online counselor, these actions, in whole or in part, cannot guarantee the security of Internet transmissions. I permanently agree to release and indemnify LDS Hope and Recovery from all suits, claims, and other actions originating from psychotherapy provided through LDS Hope and Recovery.

Appointments: Our appointments are your time to use as you wish. Those that are not utilized, or are canceled without sufficient advanced notice, will be charged at the full fee. “Sufficient notice” is at least 24 hours, and more. Appointments that exceed 50 minutes will be charged according to the hourly rate. Pease not that phone calls or any correspondence to the client or any third party individuals that exceeds 10 minutes will be charged at the hourly rate. Please also note that third party payers will not reimburse you for the charges of missed appointments. Messages can be left at (888) 200-7951

Fees and Billing: Our services are based on a fee-for –service contract. Please be prepared to pay for services at the time of appointment. In special circumstances, payments can be delayed, but this must be arranged with your therapist, and interest will accrue at a rate of 1.5% per month. In the event that full payment for charges incurred is not made, you will pay all costs osf collection, court cost, and attorneys’ fees.

Insurance Coverage: Your work with your therapist may be covered by your health insurance. Please remember expenses. Generally we ask for full payment at the time of each visit. We will provide to you the information and receipts that are necessary for most insurance companies. If this is not sufficient, we will help you in filling out an initial report or company claim. Laws regarding information given to insurance companies are included in HIPPA regulations.

Confidentiality: Professional ethics, as well as the laws of the State of Utah, require that we honor your right to privacy and the confidentiality of our work together. We will not provide information about you to others without your informed consent and written permission except as required by law. We must report clear and present danger to human life and any form of child or elder abuse, as well as infectious diseases. Minors and Parents: Clients under the age of 14 who are not yet emancipated and their parents may allow parents to examine their child’s records unless deemed harmful to the child. Our policy is for clients 14-18 and parents to contract about general information that can be shared with parents. Laws regarding court proceedings are included in HIPPA regulations.

Emergency Coverage: We do not provide 24 hour emergency coverage at this office. In case of emergency, you may leave a message with my 24 hour answering service, and we will return you call as soon as possible. If you are unable to make contact with your therapist personally, we recommend that you contact your family physician, local hospital emergency room, or the crisis unit at your local mental health center.

Fees: For a 50 minute appointment $90. Please make your Payments via www.ldshopeandrecovery.com.

Your Signature:

Your typed name is considered a legal signature

I AGREE WITH THE ABOVE.


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