INFORMED CONSENT AND SERVICE AGREEMENT FOR COUNSELOR COBBLER JOHN’S COUNSELING & LIFE COACHING ONLINE

Rob “John” Garner, MA, LMHC, LPC

@ www.CounselorCobblerJohn.com

I understand that mental health counselors licensed in the State of Washington and professional counselors licensed in the State of Oregon are required by law to furnish their clients with information regarding their therapeutic orientation and approach to counseling; formal education and training; fees, payment and billing policies; continuing education; and other responsibilities and rights of clients.

CURRENT PRACTICE

I understand that these online counseling & life coaching services are limited to adults over 18 years of age as individuals and couples and delivered exclusively online through a live real-time video conferencing format. I understand that to engage in online video counseling & life coaching services I must be an adult over 18 years of age; not suicidal or a threat to others; not in an abusive or violent relationship; and not seriously and deeply depressed.  For these conditions, online counseling & life coaching is not typically the most appropriate or most effective avenue for treatment.

PROFESSIONAL QUALIFICATIONS

Master of Arts in Counseling Psychology, Lewis & Clark College, 1988.

Licensed Mental Health Counselor (LMHC), State of Washington, LH# 00003942. Verify here

Licensed Professional Counselor (LPC), State of Oregon, C# 0699. Verify here

Professional Affiliations include: Washington Department of Health, Oregon Board of Licensed Professional Counselors & Therapists.

ORIENTATION & APPROACH

I (Mr. Garner) see counseling & life coaching as a creative, dynamic relationship between client and counselor/life coach in which the concerns and interests of the client are the priority and the focus of treatment. It is my role as counselor/life coach to use my professional knowledge and skills to assist you in clarifying your concerns; identifying specific problems; and generating new ways of working through your present situation which will bring you satisfaction and reduce the level of unhealthy emotional pain in your life. I firmly believe that the best results in counseling & life coaching are achieved when the client is both encouraged to be in control of their own life and willing to play an active role in treatment. Because there are many ways to work on a problem, my approach is unique to the individual and may change if its effectiveness is in question. My theoretical orientation is eclectic, which means that my counseling & life coaching approach is not guided by one particular theory, but is influenced by a number of sources and schools of thought.

Though I am qualified to diagnose people and assign a diagnostic code of mental illness, I will not provide you with a formal diagnosis that would enter into your health history and is also a requirement for billing insurance companies. By avoiding the use of insurance, you also avoid a diagnosis of a mental disorder in your medical records, which many insurance and job applications require you to disclose. Even though the majority of people using their insurance to pay for services have noticed no change in their personal insurability, health insurance premiums or employability, as a result. Such an occurrence is possible. It is my practice that suspension, termination, or referral shall be discussed between us if a pattern of behavior shows a disinterest or lack of commitment; or if any unresolved conflict or impasse between us occurs. By the end of our first session, if I find that your concerns require qualifications out of my area of expertise, then I will offer appropriate referrals. On a session-to-session basis, I will evaluate the suitability of online counseling & life coaching care for addressing your stated concerns. If in my clinical judgement, I come to believe that you will or might require in-person care at some point, I shall inform you of my opinion, explore your ideas, discuss clinical options and recommend that you secure a face-to-face provider within your own community.

FEES & PAYMENT

I understand that services are to be pre-purchased on the website and all major credit and debit cards are accepted. I understand that all of my personal and financial information is stored, maintained and secured exclusively by my credit and debit card company. I understand that video counseling & life coaching services are provided at the rate of $90.00 per 50 minute session and are payable by credit and debit cards through Stripe (billing software linked to 10to8 scheduling software) prior to the counseling & life coaching session and are non-refundable. I understand that refunds can be granted only in the instance of Mr. Garner being unavailable at the time of a session (services not rendered). I understand that fees cannot be refunded in the instance in which I miss a session. If I decide not to participate in online counseling & life coaching, or my perception that Mr. Garner’s services are not helpful, I will not reschedule. I understand that health insurance plans will not be accepted or billed to cover the cost of Mr. Garner’s online counseling & life coaching services.

I understand that payment is made through the website’s online payment terminal Stripe, which is linked to the 10to8 scheduling software and I confirm ownership of any credit and/or debit card being used for payment. When scheduling a counseling & life coaching session, I understand and agree that the amount of the session fee will be charged against my credit and/or debit card, Stripe or Direct Debit account. I have been made fully aware of, and give expressed consent willingly and knowingly for such authorization for the fees disclosed to me prior to my willing entrance into the fee-based video counseling & life coaching session. I understand that I am responsible for all charges associated with connecting to the video counseling & life coaching services. I agree that any charges incurred to access the Internet, including but not necessarily limited to telephone charges and access fees billed by my Internet Service Provider, are entirely my responsibility. Depending on my particular location and chosen Internet Service Provider, I understand that I may be subject to long distance charges and/or other communication surcharges, which are my responsibility. No sales tax will be added to the published prices on these purchases.

POINT-OF-SERVICE

Mr. Garner has fully disclosed his professional credentials and licenses on his website, along with links to the licensing bodies involved for verification. He has made it clear that he is licensed as both a mental health counselor in the State of Washington and a professional counselor in the State of Oregon. If my residence is outside the State of Washington or of Oregon, I understand that I am soliciting services of a professional outside of my state of residence. Further, I agree that the location of these counseling & life coaching services or “point-of-service” is where his state of residence and licensure is and not my own. I understand that this means that my counseling is under the licensing rules and laws of the State of Washington and of Oregon. I understand that I am using the Internet (the “information highway”) to virtually travel to Mr. Garner’s state of professional practice. Hence, Mr. Garner is accountable to and agrees to abide by the ethical and legal guidelines prescribed by these states of licensure and residence, which is currently the State of Washington. I understand that legally, I am visiting him at his location and the laws of that location are the laws that will govern my counseling & life coaching services, even if that session is online. I understand that licensing rules are different for each state and country. I hereby confirm that I consider our meetings to occur in cyberspace and that Mr. Garner does not claim to be licensed in my state or country of residence unless I live in the State of Washington or of Oregon. If my state of residence has laws regulating with whom I may seek counseling online, I am responsible for informing myself and complying with such laws. I accept full responsibility for my decision to work with Mr. Garner under these conditions and by soliciting his professional services, I am agreeing to these terms. Also, I am freely choosing to enter into online counseling & life coaching, and I understand that I may discontinue at any time.

APPOINTMENTS

I understand that counseling & life coaching sessions are scheduled in advance by appointment and are 50 minutes in length. If I am late for my scheduled appointment, the session will not be extended to redeem this time. I understand that scheduled appointments may be cancelled without charge if the cancellation occurs more than 24 hours in advance or in the event of death or hospitalization. If I have to cancel my appointment or fail to appear with less than 24 hours’ notice, then I will be charged for my appointment since Mr. Garner will not be able to schedule anyone else. I understand that if there is a technology failure (e.g., power failure, DSL down, etc.) on either my or Mr. Garner’s part, prior to our scheduled session, the session may be rescheduled for a later date or time. If technology fails during a session, Mr. Garner will first attempt to reconnect to me online. If that fails, I will be contacted through email to make further arrangements or refund my money. I understand that if I do not return his email by the time our session would have ended, I will be charged for that session as a missed appointment.

ADVANTAGES & LIMITATIONS/BENEFITS & RISKS

I understand about the advantages & limitations, benefits & risks as well as the alternatives to video counseling & life coaching. I understand that the advantages and limitations of online counseling & life coaching will directly affect me. Some of the advantages of online video counseling & life coaching include convenience, affordability, flexibility, increased sense of safety and assertiveness, anonymity, greater selection of counselors, easier access to services and decreased social stigma. I understand that the limitations of online video counseling & life coaching include, but are by no means limited to, pragmatic challenges of building rapport over a distance, technological security and confidentiality, crisis response issues, and the potential for online counseling & life coaching to be less effective treatment than in-person services. I understand that there are potential risks and benefits associated with any form of counseling & life coaching, and that despite my efforts and the efforts of Mr. Garner, my condition may not improve, and in some cases may even get worse, due to experiencing feelings like stress, sadness, guilt, and frustration. I understand that I may not agree with Mr. Garner’s assessment, perspective, or treatment recommendations. I understand that disagreement does not constitute a refund of Mr. Garner’s fees. I understand that the benefits of online video counseling & life coaching can be profound and may include improved mood, resolved personal problems, improved/healed relationships with others, better self-image/self-esteem, and improved mental or behavioral functioning.

I understand that I should weigh the benefits against the limitations of these counseling & life coaching services before consenting to the online video life coaching & counseling treatment process. I understand that I may benefit from online counseling & life coaching, but that the results cannot be guaranteed or assured. I understand that online counseling & life coaching is not an alternative to an in-person medical evaluation or treatment. I agree that should I present with medical problems, I should immediately consult with a physician. I understand that examples of traditional therapeutic alternatives to online counseling & life coaching are: face-to-face counseling from a mental health professional; finding a support group in the community; using family or friends as supports; and reading self-help books.

CRISIS SITUATIONS

In the event of a medical, psychiatric, or other situation requiring face-to-face crisis intervention, I understand that it is my responsibility to seek such help. If I am currently considering or threatening suicide or any form of harm to myself or others, I take full responsibility for seeking appropriate help immediately and for any action I may take. Such help might include any or all of the following: calling 911 and/or local crisis line; contacting appropriate police or emergency medical personnel; or going to the nearest open clinic and/or hospital emergency room. I understand that the following online nationwide crisis intervention and help resources in the United States are available: Poison Control: 1-800-222-1222; Child Abuse Hotline: 1-800-422-4453; Sexual Assault Hotline: 1-800-656-4673; Domestic Abuse Hotline: 1-800-799-7233; Suicide Prevention Hotline: 1-800-273-8255.

CONFIDENTIALITY & SECURITY

I understand that my privacy, security and anonymity are very important and in good faith every effort will be made to make sure I feel 100% comfortable and safe during my counseling & life coaching experience. While accessing services, I understand that there is a three-step process: Schedule & Pay; Read & Agree; and Come & Meet. I understand that the Schedule & Pay process will link me to an automatic scheduling software program called 10to8, which is linked to a payment process program called Stripe. I understand that this program secures my information by using bank-grade encryption and will enable me at the same time to make an appointment via 10to8 and secure it with a Debit and/or Credit Card through Stripe. I can choose a nickname, or pseudonym during the process of scheduling for services. This is the only name that will be shown to Mr. Garner and that it is completely up to me whether or not I reveal my real name. I understand that during this process, I will be asked to provide a valid e-mail address. I understand that I am responsible for safeguarding and maintaining the confidentiality of my login nickname and agree not to disclose it to any third party. I understand that it is strongly recommended that I do not use these services on public computers and not to store any confidential information through a web browser or other software. I understand that my video counseling & life coaching experience is provided on a secured telephone line and is completely browser-based (currently limited to updated version of Google Chrome). I understand that all I need is a computer with a built-in camera or webcam and an adequate Internet connection with no need to download or install any software. I understand that video counseling & life coaching sessions are not recorded or stored but are encrypted end-to-end and that any information regarding my identity, written or discussed online is protected by the confidentiality laws of the States of Washington and of Oregon. I acknowledge and accept that it is Mr. Garner’s intention not to be taking notes regarding our counseling/life coaching sessions, given this practice of not taking notes is legal in the State of Washington where he and his practice resides.

Further, I understand that except in rare situations, information will not be released to anyone without my written permission. I understand that limits of confidentiality differ from state to state. I understand that according to the laws of both Washington and Oregon the exceptions to confidentiality of information obtained in the course of services includes: reporting suspected child abuse; reporting imminent danger to self, others or property; reporting to relevant agencies; licensee consultation or supervision; and defense of claims brought by client against licensees. I understand that it cannot be guaranteed that I will be apprised of all mandated disclosures.

I understand that every effort is made to maintain the confidentiality of our communications and are Health Insurance Portability and Accountability Act (HIPAA) compliant, including but not limited to provision of using a secure server and secure socket layer (SSL) technology. I understand that no communication on the Internet can be guaranteed completely free from potential breach of confidentiality in transit by hackers or Internet Service Providers or by others who had access to the account or the computer. I understand that the transmission of information via the Internet is not completely secure and I acknowledge that the security of data that I send over the Internet is not guaranteed and that I send my information at my own risk. I understand that at the present time total security with online communication is not absolute in any medium and therefore needs to be at my own risk, even though the chances of someone having the expertise or the interest to hack into conversations is rather rare.

I take full responsibility for the security of any counseling records on my own computer and in my own physical location and will not hold Mr. Garner liable for any breach of confidentiality regarding electronic or paper records taking place on my end. I understand that the following information will be collected and processed about me: information that I provide when I register for counseling & life coaching; information that I submit when I schedule for a counseling & life coaching session; information about me, which I include in any e-mails that I send; information about my usage of the website; and information about my computer, which may include my IP address, operating system and browser type for system administration. Any payment transactions will be encrypted using SSL (secure socket layer) technology. I understand that my information will only be held for a reasonable period of time, or as long as the law requires or permits. I understand that once my information is received, appropriate security measures will be adopted to protect my information from access by unauthorized persons and against unlawful processing, accidental loss, destruction, and damage. I understand that standard e-mail is not a secure means of communication and that there is some risk that any protected health information contained in e-mail may be disclosed to, or intercepted, printed, or stored by unauthorized third parties. Consequently, the security or confidentiality of messages sent by e-mail cannot be ensured.

CONTINUING EDUCATION

I understand that mental health counselors licensed in the State of Washington and professional counselors licensed by the State of Oregon are required by law to possess a minimum of three years full-time, board-approved, supervised experience and complete 20 hours of approved continuing education each year as a means to enhance and upgrade professional counseling knowledge and skills. I understand that licensed counselors in each state agree to maintain valid mental health licensure and remain in good standing as well as possess professional liability insurance (minimum 1 million occurrence/3 million aggregate).

RIGHTS & RESPONSIBILITIES

I have read the information regarding my client rights and responsibilities that were linked within Mr. Garner’s website. I understand that if I find the services provided to be unethical or unprofessional, I have the right to issue a complaint to the Washington Department of Health and/or the Oregon Board of Licensed Professional Counselors & Therapists. I understand that Mr. Garner subscribes to the Code of Standards & Ethics for licensed counselors of both the State of Washington and of Oregon.

DISCLAIMER & LIMITS OF LIABILITY

As a customer of online counseling & life coaching services, I accept full responsibility for conducting my session in a safe environment, as well as providing the necessary equipment to conduct the online counseling & life coaching session. I understand that use of the services and content is at my sole discretion and risk, and that the services and content, and all materials, information, products and services included therein, are provided on an “As Is” and “As Available” basis without warranties of any kind. Further, I accept all risk as to the effectiveness of the treatment and specifically waive my right to legal action or to cancel the charge with the credit and debit card company following a counseling & life coaching session, unless Mr. Garner is in breach of this Informed Consent and Service Agreement. I understand that Mr. Garner is not liable for the conduct of third parties listed on his website. He is not liable for damages of any nature including direct, incidental, consequential, or special damages that may occur from my use of online counseling & life coaching services or inability to access or use these services. I agree that I shall not for any reason attempt to subpoena or request that any of Mr. Garner’s records be presented in a deposition or court hearing of any kind for any reason whatsoever. I agree that I will not call Mr. Garner as a witness to give testimony in any court or judicial hearing.

SUMMARY OF TERMS

I understand that access to and use of these services requires compliance with the conditions of this Informed Consent for Counseling & Life Coaching Online and Service Agreement. I understand that by becoming a registered user and/or accessing and/or using the services, the site, or any portion of the services on the site, I agree to be bound by these conditions and all applicable laws and regulations governing these services. If I do not agree with the conditions of this Informed Consent and Service Agreement, I am not authorized to access or use these services for any purpose. I agree that certain situations including emergencies and crises are inappropriate for audio/video/computer based counseling & life coaching services. These may include me having thoughts about hurting or killing either another person or myself; having psychotic symptoms such as hallucinations (see or hear things that others do not), delusions (beliefs others may consider highly distorted and/or unrealistic) or long lasting personality disorder; having a life threatening or emergency situation of any kind; having uncontrollable emotional reactions; or if I am compromised due to abusing alcohol or drugs. I agree to refrain from use of these services for any purpose—or in any method—that violates any local, state, federal or international law; or engage in any conduct that could cause damage to Mr. Garner or inhibit others from benefiting from, or using, these services online. I understand that Mr. Garner may, without notifying me, terminate my access to these services if I fail to abide by the conditions of this Informed Consent and Service Agreement. I understand that Mr. Garner may amend this Informed Consent and Service Agreement or impose new conditions at any time by publishing new terms on his website. It is agreed that if any part, term, or provision of these terms and conditions are held by a court to be unlawful, the validity of the remaining terms of this Informed Consent and Service Agreement will remain valid and enforceable. Should I have additional questions after reading this statement, I will not hesitate to ask.

ATTESTATION

I attest that I am an adult over 18 years of age and agree to all information outlined in the Informed Consent and Service Agreement for Counselor Cobbler John’s Counseling & Life Coaching Online  form above. On scheduling and making prepayment through the Schedule & Pay button link for my first video counseling & life coaching session, I clicked on the Read & Agree button link following confirmation of informed consent and secured a copy of the Informed Consent and Service Agreement for Counselor Cobbler John’s Counseling & Life Coaching Online for myself.

I sent Mr. Garner a confirmation email to this email address (click the following address hyperlink): john@counselorcobblerjohn.com and on the Subject Line I wrote the following: Informed Consent & Service Agreement. In the Body of the e-mail, I typed the following (copy & paste the following): I have read, understand, and agree to the statement on Informed Consent and Service Agreement for Counselor Cobbler John’s Counseling & Life Coaching Online regarding online counseling & life coaching with Rob “John” Garner, LMHC, LPC.” At the end of this statement, I typed my Nickname that he will know me by as my electronic signature confirming my agreement to this Informed Consent and Service Agreement.

I understand that upon Mr. Garner’s receipt of this email confirmation, he will send to me a reply to this email acknowledging receipt of this email confirmation and include his electronic signature in a return email for my records. I understand that this step complies with the state mandate that clients receiving counseling services as well as the state licensed counselors providing these services must both sign their names in agreement of the terms of this Informed Consent and Service Agreement. I understand that this second step is completed only once (unless this consent/agreement is revised) and after completed I may access Mr. Garner’s services at my and his discretion through the Come & Meet link that will take me to his HIPAA compliant cyber-waiting room, which is a browser-based software program called Doxy.me.

 

Washington Mental Health Counselors, “What to Expect Brochure”

Click this PDF link to view brochure: here

Oregon Licensed Counselors and Therapists, “What to Expect Document”

Click this PDF link to view document: here

 

RJG: 6/2016

 

 

 

 

©Counselor Cobbler John 2017