Schedule Appointment with Dr. Leslie Cary

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Notes to Business (your address or any special notes about your order)

Item	Quantity	Total
HeartFire Trauma Healing Program		$1,500.00
Total: $1,500.00

I hereby consent to TeleCoaching with Dr. Leslie Cary, Ph.D., LMFT. I understand that TeleCoaching services include the practice of coaching using interactive audio, video, or data communications. I understand that I have the following rights with regards to TeleCoaching:

1. I have the right to withhold or withdraw consent at any time without my right to future care of

treatment nor do I risk the loss or withdrawal of any treatment benefits to which I am entitled.

2. The laws that protect the confidentiality of medical information also apply to TeleCoaching. As

such, I understand that the information discussed during coaching is confidential, with certain

exceptions. Exceptions include, but are not limited to abuse of a child, the elderly, dependent adults, express threats of violence towards a specific person, and when the coach's mental or emotional state may become an issue in a legal proceeding.

3. I understand that the dissemination of any personally identifiable information or images from

TeleCoaching interaction to any other party shall not occur without my written consent.

4. I understand, as with other forms of coaching, there are possible risks and consequences from TeleCoaching/communicating by electronic communication and that Dr. Leslie Cary cannot guarantee the security and confidentiality of electronic communication. These risks include, but are not limited to, that despite reasonable efforts on the part of the coaching, the transmission of medical information could be disrupted or distorted by technical failures, the transmission of my medical information could be interrupted by unauthorized persons, and/or the electronic storage of my medical information could be accessed by unauthorized persons.

5. I understand that if my coach feels that I would be better served by another form of coaching, I will be referred to a coach who can provide such services in my area.

6. I understand that I may benefit from TeleCoaching, but that results cannot be guaranteed or assured.

7. I understand that I am prohibited from recording my TeleCoach sessions without prior consent of my coach.