Coaching Agreement

Informed consent to treatment:

The purpose of this informed consent is to provide you with some basic information about my services. Please read this form carefully, as it contains information important to your prospective coaching program. Should you have any questions regarding any aspect of my practice, please feel free to ask and we can discuss any questions that you may have. Once you have reviewed the form, I will ask you to sign it, indicating that you understand, acknowledge, and accept the information and policies described. Please keep one copy of this form for your records. A second copy, signed and dated, will be kept by me.

By signing this form, you consent to agreeing on the following principles throughout our coaching relationship:

Coach:

I will help my client identify and fully engage his or her strengths on the path to a better future.
I will ask provocative questions and encourage my client to arrive at his or her own answers whenever possible and co-create answers otherwise.
I will encourage realistic expectations and goals.
I will be direct and firm with constructive reflections when needed.
I will support my client in brainstorming creative possibilities for moving forward and navigating roadblocks.
When appropriate, with permission, and within my scope of practice, I will offer advice, instruction, and resources for improving health, well-being, and performance.
I will be punctual and responsive.
I will recognize early whether the chemistry with a client is good or not optimal. If not optimal, I will refer the client to another coach.
I will acknowledge when my client has an issue that is outside my scope of knowledge and skills and recommend other resources.

Client:

I want to improve my level of health, well-being, or performance in life or work.
I am ready to take responsibility to make and sustain changes in at least one area.
I am ready to invest at least three months to make improvements.
I will be open and honest, and I will share personal information that is relevant to my health, well-being, and performance.
I am ready to become more self-aware.
I am curious and open to suggestions and trying new things.
I understand that setbacks are normal on the path of change and necessary in order to establish new mindsets and behaviors.
I will be punctual and responsive.

Appointments:

Clients who attend coaching sessions regularly generally see more improvement than those who attend sporadically. I agree to set aside time for our regularly scheduled session times and ask that you do the same. You are asked to give 24-hour advance notice when canceling or rescheduling appointments. My voicemail is available 24-hours a day, 7 days a week, at 503-567-9443, and will record the time of your call. Failure to provide 24-hours advance notice to cancel or reschedule will result in forfeiting the fee for the missed session, and this fee will not be refunded.

Fees and payment options:

Your program consists of _____ sessions (50-minutes per session), and your program fee is $ __________. You are responsible for payment in full at the time of your session. Your payment can be made in full prior to the beginning of our coaching agreement, or payments can be made on a monthly basis at the beginning of each month of our coaching agreement. Payments can be made using cash, check, or Zelle, and these payments can be made through my website as well. It is recommended that your first payment be made within 24-48 hours after our initial consultation call, as it has been proven that self-doubt frequently comes into play when a longer span of time occurs between making the original decision to proceed with coaching and the first coaching session.

Emergencies:

In case of an emergency, you may leave a message on my voicemail at any time. In the event that you are experiencing a mental health crisis, please dial 911, go to the nearest hospital emergency room, or call the Multnomah County Mental Health Crisis Line at 503-988-4888.

Confidentiality:

With the exception of certain specific exceptions described below, you have the right to the confidentiality of your coaching program. Our meetings are protected by my professional code of ethics. I generally only take spotty notes during our sessions as a way to prompt my memory of our conversations, but standard chart notes, as are used in the medical industry, are not kept by me and are thus not available for review.

There are a few exceptions to these standards, which allow or require me to share information without your consent or authorization:

If I believe that my client represents a clear and substantial risk of imminent, serious harm to themselves, another person, or the public, I may be required to take protective actions (e.g., contacting the police, seeking hospitalization for the client, or notifying the potential victim).
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.
If I believe that you are abusing a child or vulnerable adult, I must inform the appropriate authorities (e.g., police, Child Protective Services).
I may have to release my notes when ordered to do so by a court or pursuant to a valid subpoena.
If a client files a complaint or lawsuit against me, I may disclose relevant information regarding the client in order to defend myself.

If you elect to communicate with me by email or text, please be aware that email is not completely confidential. Any email/text that I receive from you, and any responses that I send to you, may be discoverable.

If any situation arises where I may need to release information, I will make every effort to fully discuss it with you before taking any action, and I will limit my disclosure to what is necessary.

While this written summary of exceptions to confidentiality should prove helpful in information about potential problems, it is important that we discuss any concerns that you may have now or in the future.

Risks and Benefits:

Research has shown that the majority of people who engage in appropriate coaching benefit from such experiences. For example, clients report that coaching results in improvements in their level of health, well-being, and/or performance in life and work that interfere in their lives. Unfortunately, some clients do not report improvements, and some report that their issues worsen as a result of coaching, although this is rare. Even for the majority of clients who report significant improvements, coaching usually involves some increases in discomfort when, for example, fears are faced and difficult problems are explored. In some cases, changes that you make as a result of coaching may lead to changes, positive and/or negative, in a variety of life venues (e.g., relationships). Please bring up for discussion any concerns, questions, or thoughts that you may have about potential risks and benefits of coaching. Coaching is optional, and at all times you have the right to decline coaching and/or change your mind about receiving coaching from me.

Client Consent to Coaching:

I have read this statement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I understand the limits of confidentiality required by law. I consent to pay the fees as noted above. I understand my rights and responsibilities as a client and my coach’s responsibilities to me. I agreed to undertake coaching with Anne M. Hirsch, M.D., FACP. I know that I can end coaching at any time that I wish, and that I can refuse any requests or suggestions made by my coach.

Signature of client: Date:

Get in Touch with Anne Today!

Please feel free to reach out to me at any of these links if you have any additional questions or concerns that were not addressed here.

Email: amhirsch@physiciancoachingwithanne.com

Phone: 503-567-9443