Grief Coaching Agreement

pet loss dc

Jessica Kwerel, LPC, LCPC
www.petlossdc.com
jessica@petlossdc.com
(202) 642-2682

I am looking forward to working with you and supporting you through this difficult time. Please read this information carefully. The purpose of this Agreement is to set forth the details about working together so that we both are clear as to what each of our respective roles are and how our communication will take place so that our time will be positive, productive, and comfortable. Please read the entire document carefully and be sure to ask any questions that you may have regarding its contents.

This Agreement is being made between Jessica Kwerel, LPC, LCPC (“me”) and the individual named at the bottom of this document (“Client” or “you”). We both agree to the following:

Coaching Session Description

I provide grief coaching services via doxy.me, a secure live video online platform, or Zoom for Healthcare professionals. Both platforms are HIPAA-compliant. All sessions are secure and private. Each session is 60 minutes.

Scheduling and Timing

Communication:

I try to be attentive as possible to my clients. Email contact is available at jessica@petlossdc.com. I will do my best to respond to you within 24 hours on weekdays. On weekends and holidays, I will do my best to reply to you by the next business day. Any e-mails, calls or texts to me related to your Coaching Session are for quick questions and you will receive brief responses.

Rescheduling:

If you need to reschedule your Coaching Session, you need to do so at least 24 hours in advance of your scheduled time by sending an e-mail to me.

Cancellation and Late Arrival Policies

Our time together is important. If you need to cancel your coaching session, you need to do so at least 24 hours in advance of your scheduled time by sending an e-mail to me. You will be charged the full session fee for missed appointments or failing to cancel your appointment at least 24 hours in advance. If you arrive late to your session, the length of the session will not be extended beyond your allotted time, and you will be charged the full appointment fee. If you are more than 20 minutes late to your scheduled appointment — this is considered a “no-show. The session will automatically terminate, and you will be charged the full session fee.

Coaching v. Therapy: The services being provided are coaching services, not therapy.

Even though I am a licensed therapist, this modality that you are choosing is not therapy. Therapy and coaching are similar in many ways but coaching does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association. Coaching focuses on the “here and now” and does not explore your past, such as your childhood or any family of origin issues. Coaching is a goal oriented approach. By signing you agree that you understand that coaching is not a substitute for counseling, psychotherapy, social work services, psychoanalysis, mental health care or substance abuse treatment and you will not use it in place of any form of diagnosis, treatment or therapy. By signing this Agreement, you are agreeing that you understand the difference in these two functions and you will get appropriate professional help for mental health issues if necessary. Please free to ask questions at any time.

Coach-Client Relationship

You are solely responsible for creating and implementing your own physical, mental and emotional well-being, decisions, choices, actions and results arising out of or resulting from the coaching relationship and your interactions with the me. As such, you agree that I am not and will not be liable or responsible for any actions or inaction, or for any direct or indirect result of any services provided by me. You acknowledge that coaching is not therapy and does not substitute for therapy if needed, and does not prevent, cure, or treat any mental disorder or medical disease.

You further acknowledge that you may terminate or discontinue the coaching relationship at any time.

You acknowledge that coaching is a comprehensive process that may involve different areas of your life. You agree that deciding how to handle these issues, incorporate coaching principles into those areas and implementing choices is exclusively your responsibility.

You understand that in order to enhance the coaching relationship, you should communicate honestly, be open to feedback and assistance and to create the time and energy to participate in our work together.

Confidentiality   

As a Licensed Professional Counselor, there are some situations in which I am legally obligated to breach confidentiality in order to protect you or others from harm. If I have information that indicates that a child or elderly or disabled person is being abused, I must report that to the appropriate county/state agency. If you report or appear, in my professional opinion, to be at imminent risk to harm yourself, or you make threats of imminent violence against someone else or property, I am required by law to take protective actions.  

As your coach I am ethically bound to protect the confidentiality of our communications and will do so. I will only release information about our work to others with your written permission or in response to a court order. These situations are quite rare in coaching practices. If such a situation occurs in our relationship, I will make every effort to discuss it with you before taking any action.   

Please note that it is impossible to guarantee the confidentiality of information that is transmitted electronically. This is particularly true of e-mail and information stored on computers that are connected to the Internet; especially when there is not some form of security protection in place.   Please take proper precautions to protect any sensitive or private information that you wish to share with me. 

By signing this Agreement, you acknowledge that you have read, understand, agree to and accept all of the terms in this Agreement. Electronic signatures of this Agreement are permitted and enforceable. You agree that you have had the opportunity to ask me any questions prior to signing, and your signature indicates that you agree with all of the terms of this Agreement. In signing this agreement, you as a client will indemnify and hold Jessica Kwerel harmless from any legal claims, actions, or judgments. Please retain a copy of this Agreement.

esignature

Per the ESIGN Act, your esignature is legally binding. By signing your name electronically below, you are agreeing that your electronic signature (or esignature) is the legal equivalent of your manual signature.