LDS Hope and Recovery Online Consent Form We welcome you to the LDS Hope and Recovery, and hope that you will find your work with us to be healing and meaningful. The following information is important for your consideration. Your goals are more likely to be met when you understand the nature and limitations of professional coaching. Scope & Relationship LDS Hope and Recovery hires Masters of Doctorate level mental health counselors, however the online nature of our work requires that we call our work with clients Coaching. You will not be diagnosed with a DSM diagnosis and our work with you will be considered limited to the scope of coaching. Goals & Outcomes Coaching is most useful in helping individuals and or couples help themselves or improve their relationships by changing feelings, thoughts, and or behaviors. You determine the nature and amount of change you wish to make. Benefits & Risks Most people experience improvement or resolution to the concerns that brought them to coaching with us, but of course, there are no guarantees, and there are some risks. For example, coaching could open up new levels of awareness that may cause discomfort. A person must be 18 years of age or older to consent for coaching by LDS hope and recovery. (Any under 18, a parent or legal guardian must provide a written consent for services.) Confidentiality We understand that the information you share in coaching can be very personal and that you may not want it discussed with others without your authorization. By signing this Description of Services, you acknowledge that you have been informed of your rights regarding confidentiality. LDS Hope & Recovery will not release confidential information without a signed Authorization to Release Confidential Information form, unless such release is otherwise authorized or required by law. For example, the law may require us to disclose confidential information if there is reason to believe that a child or elder has been abused or neglected, or that you may be in danger of harming yourself or others. As a client of LDS hope and recovery you declare that you are free of suicidal thoughts. Also, although LDS Hope and Recovery has taken steps to ensure confidentiality and privacy of online communications between you and your online coach, these actions in whole or in part cannot guarantee the security of internet transmissions. You permanently agree to release and indemnify LDS Hope and Recovery and its employees and associates from all suits, claims, and other actions originating from coaching provided through LDS Hope and Recovery. Payment of Services The fee for an intake, individual, or couple session lasting 80 minutes is $205. The fee for a 50-minute individual or couples session is $135. Additional time may be agreed to in one half hour increments billed at $70 per half hour. Group work is $180 per month, which will most often consist of one 80-minute session per week. Clients are responsible for self billing and payment of services. Excluding the assessment which requires pre-payment, payments are made on the ldshopeandrecovery.com website at the conclusion of each visit. For your convenience, we use paypal and accept all credit cards that they accept currently. When requested, we can bill your bishop or ecclesiastical leader if he has authorized payment. If you indicate that a bishop or other ecclesiastical leader will be paying for any portion of your bill, an Authorization to Release Confidential Information form must be signed to allow contact with the Bishop or ecclesiastical leader. If your leader changes during the course of your work, you must discuss your arrangement with the new leader, notify LDS Hope and Recovery, and sign a new release form. Late Payments One way we keep our cost per session down is by not having to hire specific billing staff. As such if you fail to pay as described above, there is a 15% invoicing fee/late fee for any amount that is 15 or more days past due. Please be aware that your next appointment is subject to hold or cancellation at the discretion of the coach if you are behind on payments. Cancellation Policy On occasion, a situation may arise which prevents you from keeping a scheduled appointment with your coach. As a courtesy to your counselor, it is required that you give at least 24 hours advance notice of your appointment if you cannot keep it. Except in emergency situations, you will be personally charged the full amount of the session for late cancellations or for no-shows. If you are more than 15 minutes late to a session the session will be closed and considered a no-show. Grievance Policy If you have concerns about any aspect of the services you are receiving you should address the matter with your coach first. If you are unable to find a resolution to your concerns, you may talk with a supervisor. You also have the right to discontinue services at any time, for any reason, without prior notification or explanation to LDS Hope and Recovery. (A note explaining any decision would be appreciated.) Question you may want to ask your therapist/coach What is your background? What do you feel most qualified to treat? Following the assessment interview – How do you intend to help me? What other resources such as support groups, marriage counseling, family therapy, etc. can you refer me to? If a referral is recommended, how will it be handled? I have read the above information, and understand that I am encouraged to ask questions and give input regarding the coaching work at any time. If there is anything in this form that I do not understand, it is my responsibility to seek clarification. Fees: For a 50 minute appointment $135. 80 minute appointments are $205. Weekly group sessions are $180 per month. Please make your Payments via www.ldshopeandrecovery.com. Your Signature: Full Name: * Your typed name is considered a legal signature Date: * I AGREE WITH THE ABOVE. It is my understanding that payment arrangements are as follows: Self Pay % Bishop/ Other Pay % Page 2 Leave a Comment Cancel ReplyYou must be logged in to post a comment.