Consent

Date

This contract indicates consent for distance-oriented counseling or coaching, which take place over a HIPAA compliant telehealth platform.

By signing this contract, I agree to the following:

• To find a quiet and protected space for our virtual sessions.

• Sessions should not be cancelled or changed with less than 48 hours notice unless illness is the reason given. Otherwise there is a late cancel or ‘no show’ fee charged.

• That during our session time, no one else will be present in the room (unless indicated to the coach and discussed prior to session).

• That no phone calls, texts, emails or web surfing will occur.

• That if there is a loss of connection, the counselor or coach will initiate the call back.

• Sessions are scheduled for 60 minutes to account for any connection disruption, but the session shall last 40-45 minutes.

• The session and the chat will not be recorded nor will screen shots be taken unless expressly discussed prior to session and with clinical goals in mind.

• All rules regarding mandated reporting and reporting harm to self or others remain the same as in office sessions as per LMFT / LPC / LCSW / PsyD / Counselor or Coach ethical standards and legal protocol.

• In case of a crisis an address and contact information on campus needs to be given to the counselor or coach before sessions begin.

By signing this contract, I indicate my compliance with the above stated expectations. I reserve the right to revoke my consent, in writing, at any time. This consent will be valid for 1 year following the date of signature

Client Name

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