Sava Wellness Consent Form

Description of Coaching/Wellness Support

Coaching/Wellness Support is a partnership (defined as an alliance, not a legal business partnership) between the Coach and the Client in a thought-provoking and creative process that inspires the client to maximize personal and professional potential. It is designed to facilitate the creation/development of personal, professional or business goals and to develop and carry out a strategy/plan for achieving those goals. However, coaching/wellness support is not professional mental health care or medical care nor designed to be a substitute thereof. If you feel psychologically stressed to the point that it is interfering with your ability to function, we encourage you to seek the help you need in the form of a professional counsellor. Coaching/wellness support may augment your therapy, but the work of coaching/wellness support is meant to be done when major emotional and psychological wounds are already healing or healed. 

In that spirit, by purchasing coaching/wellness support services from your Coach, you confirm that you have read and agreed to each statement and that you wish to proceed: 

• I understand that the coaching/wellness support services I will be receiving from my Coach are not offered as a substitute for professional mental health care or medical care and are not intended to diagnose, treat, or cure any mental health or medical conditions. I also understand that my Coach is not acting as a mental health counsellor or a medical professional. 
• I understand my Coach is not acting as a mental health counselor or a medical professional. 
• I understand that coaching/wellness support is not a substitute for counseling, psychotherapy, mental health care, substance abuse treatment, or any other form of professional support and I will not use it as a place of any form of therapy. 
• I acknowledge that coaching/wellness support does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association and that coaching/wellness support is not to be used as a substitute for counseling, psychotherapy, psychoanalysis, mental health care, substance abuse treatment, or other professional advice by legal, medical, or other qualified professionals and that it is your exclusive responsibility to seek such independent professional guidance as needed. If you are currently under the care of a mental health professional, it is recommended that you promptly inform the mental health care provider of the nature and extent of the coaching/wellness support relationship agreed upon by you and the Coach. 

• I acknowledge that I am solely responsible for creating and implementing my own physical, mental, and emotional well-being, decisions, choices, actions, and results arising out of or resulting from the coaching/wellness support relationship, the coaching/wellness support calls, and interactions with the Coach. As such, you agree that the Coach is not and will not be liable or responsible for any actions or inactions, or for any direct or indirect results of any services provided by the Coach. You understand that coaching/wellness support is not therapy and does not substitute for therapy if needed, and does not prevent, cure, or treat any mental disorder or medical disease.
• I understand that coaching/wellness support is, at present, an unregulated industry and that my Coach is not licensed by any internationally recognised regulator. I also understand that for all legal purposes, the services provided by my Coach will be considered to be provided from any remote location worldwide or otherwise in Canada. 
• I understand and agree that I am fully responsible for my well-being during my coaching/wellness support sessions and thereafter, including my choices and decisions.
• I understand that all comments and ideas offered by my Coach are solely for the purpose of aiding me in achieving my defined goals. I have the ability to give my informed consent, and hereby give such consent to my coach to assist me in achieving such goals and aims. 
• I acknowledge that coaching/wellness support is a comprehensive process that may involve different areas of my life, including work, finances, health, relationships, education and recreation. I agree that deciding how to handle these issues, incorporate coaching/wellness support principles into those areas, and implementing choices is exclusively my responsibility.

• I understand that to the extent our work together involves a career or business, my Coach is not promising outcomes included but not limited to increased clientele, profitability, and/or business success. 
• I understand that my Coach will protect my information as confidential unless I state otherwise in writing. If I report child abuse, elder abuse, neglect, or threaten to harm myself or someone else, I understand that necessary actions will be taken and my confidentiality agreement limited in this capacity. Furthermore, if my Coach is ordered by a court to provide information or to testify, they will do so to the extent that the law requires. 
• I understand that the use of technology is not always secure and I accept the risks of confidentiality in the use of email, text, phone, Zoom, and other technology. 
• I further acknowledge that they may terminate or discontinue the coaching/wellness support relationship at any time.
• I understand that in order to enhance the coaching/wellness support relationship, I agree to communicate honestly, be open to feedback and assistance, and create the time and energy to participate fully.
• I hereby release, waive, acquit and forever discharge my Coach, any agents, successors, assigns, personal representatives, executors, heirs, and employees from every claim, suit action, demand, or right to compensation for damages I may claim to have or that I may have arising out of acts or omissions by myself or by my Coach as a result of the advice given by my Coach or otherwise resulting from the coaching/wellness support relationship contemplated by this agreement. I further declare and represent that no promise, inducement, or agreement not expressed in this agreement has been made to me to sign this agreement. This agreement shall bind my heirs, executors, personal representatives, successors, assigns, and agents. 

* I understand and consent to all of the above conditions.

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Signature

Confidentiality Policy

I understand that, under normal circumstances, Sarah Van Dyk will not divulge information to any person without my written consent. Confidentiality of all information acquired will be protected, except as required by law. I understand that I will be advised, if at all possible, if confidentiality must be waived. Situations where confidentiality must be waived include the following:

• Disclosure of suspected child abuse or neglect
• Disclosure of the intent to physically harm oneself or another person
• If Sarah Van Dyk and/or the client’s file is subpoenaed to court
• If the client is under 18 years of age, or has been appointed a legal guardian of the courts, certain information may have to be shared with the client’s parent/guardian

Sarah Van Dyk will keep written records of some of our appointments. The same standards of confidentiality apply to these records, and they are stored in a secure manner.

This coaching/wellness support relationship, as well as all information (documented or verbal) that you share with the Coach as part of this relationship, is bound by the principles of confidentiality. However, please be aware that the Coach-Client relationship is not considered a legally confidential relationship (like the medical and legal professions) and thus communications are not subject to the protection of any legally recognized privilege. The Coach agrees not to disclose any information pertaining to the Client without the Client’s written consent. 

Confidential Information does not include information that: (a) was in the Coach’s possession prior to its being furnished by the Client; (b) is generally known to the public or in the Client’s industry; (c) is obtained by the Coach from a third party, without breach of any obligation to the Client; (d) is independently developed by the Coach without use of or reference to the Client’s confidential information; (e) the Coach is required by statute, lawfully issued subpoena, or by court order to disclose; (f) is disclosed to the Coach and as a result of such disclosure the Coach reasonably believes there to be an imminent or likely risk of danger or harm to the Client or others; and (g) involves illegal activity. The Client also acknowledges their continuing obligation to raise any confidentiality questions or concerns with the Coach in a timely manner. 

Initial:_____

Cancellation Policy

I acknowledge that I am required to provide Sava Wellness with at least 24 hours notice if cancelling an appointment. I understand that failure to provide 24 hours notice will result in a full session charge with no exceptions. 

Initial:_____

Fees

I understand that the fee for each session is based on the standard 50 minutes of meeting time and 10 minutes of administration time. 

Initial:_____

Technology and Informed Consent

Please take a moment to fill out our intake form before your session. Zoom is a platform that enables Sava Wellness to provide support services via secure internet technology. It has the same purpose as in-person face-to-face support sessions. Due to the nature of the technology method used, the experience of the session will be different than in-person. The Zoom session involves arranging an appointment time with you at your computer and your support Coach interfacing from their computer via the internet. 

Limitations and Informed Consent

We will agree to use the video-conferencing platform selected for our virtual sessions, and your support Coach will explain how to use it (if needed). You need to use a webcam or smartphone/phone during the session. With use of alternative methods such as Zoom, there can be a potential for misunderstandings with limited communications cues including visual/auditory cues. It is important that all parties seek clarification when questions of misinterpretations surface. Use of electronic methods such as telephone, video, and email carry potential challenges. There is a risk that the session could be disrupted or distorted by unforeseen technical problems. Due to reliance on technology and its related limits, there may be experiential differences compared to face-to-face services.

Technology Limitations

There may be implications of technology-related complications (e.g., time delays, equipment failure, and poor internet speeds). We need a back-up plan (e.g., email where you can be reached) to restart the session or to reschedule it, in the event of technical problems.

Despite every effort to use secure methods, information transmitted via the internet may not be guaranteed to be secure.

Confidentiality Limitations

There are exceptions and limits to client confidentiality that exist for support meetings; these are listed above. It is important to use a secure internet connection rather than public/free Wi-Fi. It is important to situate yourself in a location that provides privacy and confidentiality because there is a risk of being overheard by anyone near you. Your support Coach will ensure that they are in a location that maintains confidentiality also. Despite best practices to ensure confidentiality within the session, there is a small risk that the transmission can be breached and accessed by unauthorized persons. There can be no recording of the session by either party unless agreed to by both you and your support Coach.

Consent

I provide consent to the use of Zoom for my appointments. I am aware and have been informed that I can withdraw my consent for use of Zoom at any time.

*I certify that the above information is correct to my knowledge.

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Signature

Limited Liability

Except as expressly provided in this Agreement, the Coach makes no guarantees, representations, or warranties of any kind or nature, express or implied, with respect to the coaching/wellness support services negotiated, agreed upon and rendered. In no event shall the Coach be liable to the Client for any indirect, consequential, or special damages. Notwithstanding any damages that the Client may incur, the Coach’s entire liability under this Agreement, and the Client’s exclusive remedy, shall be limited to the amount actually paid by the Client to the Coach under this Agreement for all coaching/wellness support services rendered through and including the termination date. 

Entire Agreement

This document reflects the entire agreement between the Coach and the Client, and reflects a complete understanding of the parties with respect to the subject matter. This Agreement supersedes all prior written and oral representations. The Agreement may not be amended, altered or supplemented except in writing signed by both the Coach and the Client. 

Binding Effect

This Agreement shall be binding upon the parties hereto and their respective successors and permissible assigns. Please sign prior to the first scheduled coaching/wellness support meeting. 

* I understand and consent to all of the above conditions. 

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Signature

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Full Name

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Date