Informed Consent Form

Privacy of Information Shared in Consultation/Coaching Relationship
Your Rights and My Policies

Introduction

This Agreement is intended to provide ________________________ (herein “Client”) with important information regarding the practices, policies, and procedures of Sol Smith, MFA, EdS, MS ( herein “Coach” or “Consultant”), and to clarify the terms of the consultation/coaching relationship between Coach and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Coach prior to signing it.

Information about Square Peg Coaching and Consulting, LLC

Sol Smith, MFA, EdS, MS has been a college professor, focusing on critical thinking and learning since 2002. In 2020, Sol decided to combine his cumulative experience of her years of teaching, advanced education, and lived experience as an autistic and ADHD person, to start a new venture as a Coach/Consultant. With Square Peg Coaching and Consulting, I not only provide a trusted and inviting environment but I also provide an opportunity to help provide supplementary guidance to overwhelmed people trying to live an autonomous life. I focus on helping people as they excavate and understand their challenging emotions and behaviors, while they work on the serious practice of unmasking. Every client is an individual and is treated as such, with no “off the shelf” curriculum.

The Consultant/Coach will not provide medication or prescription recommendation, engage in any physical examinations, ordering of laboratory or imaging studies, referrals, nor will he provide legal advice. These actives are beyond his scope of practice, and while I may make recommendations for you to consider, it is solely the client’s responsibility to consult with their medical provider.

What to expect:

The services provided by Sol Smith include Consultation, Coaching or TeleCoaching on topics decided jointly with you, The Client. The purpose of consultation/coaching is to develop and implement strategies to help you reach personally identified goals of enhanced performance and personal satisfaction. Consultation/Coaching may address specific personal projects, life balance, job performance and satisfaction, or general conditions in The Client's life, your relationship with your children, or parenting strategies. Consultation/Coaching utilizes personal strategic planning, values clarification, brainstorming, motivational counseling, and other counseling and consulting techniques.

When we meet, we will begin to discuss these concerns as we clarify your goals and incorporate our curriculum into your daily life. I will ask questions, listen to you, and suggest a plan for improving these problems. It is helpful if you feel comfortable talking to me about the issues that are bothering you, however, I believe our program can be beneficial with minimal self-disclosure. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their coach. Privacy, also called confidentiality, is an important and necessary part of good consultation/coaching.

Confidentiality

Our session contents and all relevant materials will be held confidential unless the Client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1.If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner where there is a substantial risk of incurring serious bodily harm, I must take steps to inform a parent or guardian of what you have told me and how serious I believe this threat to be. I must make sure that you are protected from harming yourself.

2.If a client threatens grave bodily harm or death to another person. In this situation, I must inform the person who you intend to harm and I may inform law enforcement.

3.If the Coach has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.

4.Suspicions as stated above in the case of an elderly person age 65 and older who may be subjected to these abuses.

5.Suspected neglect of the parties named in items #3 and # 4.

6.If a court of law issues a legitimate subpoena for information stated on the subpoena. I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening.

Technology Utilization

When providing telecoaching services, the Consultant/Coach uses telecoaching through Zoom. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with telecoaching services, and all existing confidentiality protections under federal and California law apply to information disclosed during those services.ng.

Internet Policy

The concern for our clients regarding the use of the Internet to communicate, especially within social media sites, is the potential loss of privacy and blurring of the coaching relationship. For this reason, we try to minimize contact on the web with both current and former clients.

•Friending: We do not accept friend requests from current or former clients on any social media site. We also do not search for or "friend" our clients.

•Texting and Email: You can choose to receive text and email reminders for your upcoming appointments. Please be aware these methods are neither secure nor private. Due to text and email communication not being secure or private, I prefer to keep messages to a minimum and discourage using these modes of communication for confidential information. If you need to contact the coach in between sessions, please call via telephone.

•Messaging: Please do not message the coach on sites such as Facebook or LinkedIn. These sites are not secure, I may not see the messages in a timely fashion, and messages on Wall posts compromise your confidentiality in a very public way. If you need to contact the coach in between sessions, please call via telephone.

Records and Record Keeping

The coach may take notes during session and will also produce other notes and records regarding the Client’s progress. Such records are the sole property of the Coach. The Coach will not alter the normal record keeping process at the request of any client. Should the Client request a copy of the records, such a request must be made in writing. The Coach will maintain client’s records for seven years following termination of the coach/client relationship. If the Client is a minor, then the Coach will maintain the records for seven years after the minor turns 18. However, after seven years, the Client’s records will be destroyed in a manner that preserves the Client's confidentiality.

Availability, Telephone, and Emergencies

The Coach’s office is equipped with a confidential voice mail system that allows the Client to leave a message at any time. The Coach will make every effort to return calls within 24 hours (or by the next business day) but cannot guarantee the calls will be returned immediately. The Coach is unable to provide 24-hour crisis service. If the Client is feeling unsafe or requires immediate medical or psychiatric assistance, they should call 911 or go to the nearest emergency room. Please do not use email or text for emergencies. If there is an emergency during our work together, or in the future after termination, where your Coach becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper care, the Coach will do whatever they can within the limits of the law to prevent you from injuring yourself or others and to ensure that your receive proper care. For this purpose, the Coach may contact your emergency contact.

Right of Refusal

The Client has the right to refuse services or recommendations at any time. The Client has the right to end services at any time, as the services provided are voluntary.

Termination of Sessions

After the first couple of sessions, I will assess whether I can benefit you. I do not accept Clients that I cannot help or that are out my scope of competence. If during our sessions I determine that you would be better served by a different service provider, I will terminate our sessions and make proper referrals where available. The main goal is to connect you with the resources that will help you the most.

If a client decides, after two sessions, to terminate coaching, the client is eligible for a refund of half the cost of the remaining sessions, after subtracting website service fees. If the client does not make contact or schedule a new session within 30 days of the most recent session, the remaining sessions will be used as a donation to future clients who cannot afford access but would be substantially benefitted.

I reserve the right to terminate sessions at my discretion or when it is legally and/or ethically appropriate to do so. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in curriculum, failure to adhere to scheduled appointments, non-compliance with the policies and procedures outlined in this document, refusal to accept recommendations for a higher level of care of supplemental care, Client behavior that is disrespectful, devaluing, threatening or otherwise inappropriate towards me, other client or any other persons present in the building, Client’s misrepresentation or omission of pertinent clinical information, the Client's needs are outside of the Coach’s scope of competence, or the Client is not making adequate progress. The Client has the right to terminate sessions at their discretion.

During the duration of your care, if two sessions are cancelled/missed without 48 business hours notice of the scheduled appointment time, the Coach may terminate services. Should Client fail to schedule an appointment for four consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, the relationship will be automatically terminated. However, I will welcome conversation about returning to Consultation and Coaching. Please see the Coaching Services Agreement for further details on our Cancellation Policy.

Upon either party’s decision to terminate these sessions, the Consultant/Coach will generally recommend that the Client participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. The Consultant/Coach will also attempt to ensure a smooth transition by offering referrals to the Client.

Written Statements of Opinion and/or FMLA/Disability Paperwork

Similarly, I do not provide statements of opinion or recommendations in written letters, reports, or forms (including court/custody cases/FMLA/clinical leave evaluations/disability paperwork). If it comes to be that you need a formal opinion during the course of our program, I will recommend that you follow up with your child’s pediatrician or mental health provider who specializes in the area of question.

Communicating with other adults:

Doctors: Sometimes your doctor and I may need to work together; for example, if you need to take medication or would benefit from seeing a counselor, therapist, or psychologist, in addition to seeing a Coach. I will get your written permission in advance to share information with your doctor. The only time I will share information with your doctor even if I don’t have your permission is if you are doing something that puts you at risk for serious and immediate physical/medical harm.

Mediation and Arbitration

All disputes arising out of or in relation to this agreement to provide coaching services shall first be rendered to mediation, before, and as a precondition of, the initiation of arbitration. The mediator shall be a neutral, third party chosen by agreement of the Coach and client(s). The cost of such mediation, if any shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Los Angeles County, California in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue(unpaid) and there is no agreement on a payment plan, your Coach can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceeding shall be able to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum.

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Signing below indicates that you have reviewed the policies described above and understand the limits to confidentiality. If you have any questions as we progress with your sessions, you can ask your coach at any time.

Client Signature ________________________________________ Date__________

Consultant/Coach Signature ______________________________________ Date__________