New Client Form-Coaching Name * First Name Last Name Date of Birth * MM DD YYYY Self-Identified Gender * Male Female Non-Binary Prefer not to answer Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Phone * (###) ### #### Preferred Email * Relationship Status * Single In a relationship Engaged Married Separated Divorced Widowed Occupation Employer Medical History: Please include: Previous/current medical diagnoses and/or if taking medications (specify if from physician or self-diagnoses). * Person responsible for payment: If self, please type your name. If someone else, please type their name and phone number. Please note that they will have to agree to our payment policy in order to charge them for your sessions. If they do not have that on file, you will be responsible for any payments due. * Payment Policy: Please type your full name to show that you understand that you are ultimately financially responsible for any balance. Better Connection Couples Therapy does not bill to any third party payers nor will we provide any information other than receipts of payment made by you to you should you decide to seek reimbursement for our services. We will obtain payment at the time of service or in the case of a late cancellation or no-show. * CANCELLATION POLICY: Type your FULL NAME here to confirm that you agree to being charged the full session fee if you do not give our office greater than 24 hours' notice should you choose to reschedule or cancel your appointment. * How did you hear about Better Connection Couples Therapy? * Emergency Contact and Phone Number: We will only contact this individual with your consent or without your consent should there be a threat to your physical safety. We may also choose to call upon 911 Emergency Services and all costs incurred will be your responsibility. * Please type your FULL NAME to indicate you have read and understand this statement: All payments will be processed through QuickBooks via credit or debit/pre-paid cards. Payments will be processed at the end of the coaching session. * Please type your FULL NAME to indicate that you have read and understand the following statement: Clients must seek the written permission of the coach before recording any portion of the session and/or posting any portion of said session on internet websites such as Facebook or YouTube. Your coach cannot become friends with clients on social media, however you are welcome to follow our account @THETHERAPYTIMES for therapy content. Better Connection Couples Therapy uses Google Meet for messaging and video communications to allow for the highest possible security and confidentiality of the content of your sessions. In order to benefit from these safeguards, the client is required to download, register and utilize the chat and video software from Google Meet. * Please type your FULL NAME to indicate you have read and understand this statement: Better Connection Couples Therapy recommends contacting local emergency services (ex. "911"), a crisis line, or an agency local to the client. Clients may utilize the following crisis hotlines in the United States: 1-800-SUICIDE or 1-800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY). * Please type your FULL NAME to indicate that you have read and understand the following: Coaching is not psychotherapy or counseling. Coaching does not address or diagnose mental disorders as defined by the American Psychiatric Association. Your coaching sessions are not a substitute for counseling, psychotherapy, mental health care, or substance abuse treatment. Psychotherapy is a healthcare service and its primary focus is to identify, diagnose, and treat mental disorders. * Please type your FULL NAME to indicate that you have read and understand the following: While we are not bound by the laws of HIPPA, confidentiality is an important element of the coaching process. Your identity and ongoing work will be kept strictly confidential. I will only release information about our work with your written permission, or if I am required by court order. The following exceptions will apply: 1. There are a broad range of events that are reportable under child protection statutes. Physical or sexual abuse of a child will be reported to Child Protective Services. When the victim of child abuse is over age 18, I am not legally mandated to report it unless I believe that there are minors still living with the abuser who may be in danger of being abused. Elder abuse is also required to be reported to the appropriate authorities. 2. If you are at imminent risk to yourself or someone else or make threats of imminent violence against another person, I will take appropriate action. * By typing my FULL NAME below, I am acknowledging that I understand the above information. I agree to hold Better Connection Couples Therapy and my coach from all liabilities and claims which may arise as a result of my participation in coaching. * Thank you!
