PARTICIPANT CONFIDENTIALITY AGREEMENT
Confidentiality in Coaching
Before you tell anyone about yourself, you have the right to know what information can and cannot be kept confidential. Please read this and initial each item only if you understand and agree to the conditions described. If there is anything you don't understand, your counselor will explain it in more detail.
Throughout the remainder of this document, the term 'coach/counselor' shall also be descriptive of the assigned coach by Eric and Elaine On Life (e2).
General Extent and Limits of confidentiality
The laws and ethics governing coaching/counseling require that coach/counselors keep all information about clients confidential except for certain types of information and situations. Those exceptions are:
1. Client's desire: If you want your coach/counselor or this agency to give information about your case to anyone outside this agency, you must sign a Release of Information giving written permission for this disclosure.
Acknowledgment: I understand that if I want my coach/counselor or this agency to give information about my case to any outside person or agency, I must sign a Release of Information
a. Risk of self-harm: If your words or behavior convince your coach/counselor that you are likely to harm yourself, either deliberately or because you are unable to keep yourself safe, your coach/counselor must do whatever he or she can to prevent you from being harmed. This means the coach/counselor must take action up to and including hospitalizing you with or without your consent. If this situation comes up, your coach/counselor will discuss it with you before taking action unless it appears that this would be unsafe or immediate action is needed to keep you from being harmed.
b. Risk of harm to others: If you threaten serious harm to another person, your coach/counselor must try to protect that person. He or she would report your threat to the police, warn the threatened person, and try to prevent you from carrying out your threat. If this situation comes up, your coach/counselor will discuss it with you before taking action unless it appears that this would be unsafe or immediate action is needed to keep you from acting on your threat.
Acknowledgment: I understand that if my coach/counselor believes there is a serious risk that I will hurt or kill myself or another person, my coach/counselor is legally required to report this, warn the endangered person if someone other than myself, and take whatever action seems needed in his or her professional judgment to prevent harm to myself or others.
c. Emergencies: In an emergency when your health or your life is endangered your coach/counselor must provide
medical personnel or other professionals any information about you that is needed to protect your life, but only information that is needed for that purpose. If possible your coach/counselor would discuss it with you and get your permission first. If not, he or she would talk with you about it afterward.
Acknowledgment: I understand that in an emergency when my health or life is in danger, my coach/counselor must give other professionals any information about me that is needed to protect my life.
If your coach/counselor obtains information leading him or her to believe or suspect that someone is abusing a child, a senior citizen, or a disabled person, the coach/counselor must report this to a state agency. To "abuse" means to neglect, hurt, or sexually molest another person. The coach/counselor cannot investigate and decide whether abuse is taking place: if the suspicion is there, the coach/counselor must report it. The state agency will investigate. If you
are involved in a situation of this kind, you should discuss it with a lawyer before telling your coach/counselor anything about it unless you are willing to have the coach/counselor make such a report. If this situation comes up, your
coach/counselor will discuss it with you if possible before making a report.
Acknowledgment: I understand that if my coach/counselor believes or suspects that a child, a senior citizen, or a disabled person is being abused or neglected, my coach/counselor must report this to a state agency who will then investigate the situation.
4. Coaching/counseling of children, families, and couples:
a. Children and adolescents: It is the policy of this agency, when a coach/counselor treats children and adolescents, to ask their parents or guardians to agree that most details of what their children or adolescents tell the coach/counselor will be treated as confidential. However, parents or guardians do have the right to general information about how coaching/counseling is going. The coach/counselor may also have to tell parents or guardians about information if their children or others are in any danger. If this situation comes up, the coach/counselor will discuss it with the child or adolescent first before talking to the parents or guardians.
Acknowledgment: I understand that if my child or adolescent is in coaching/counseling, the coach/counselor will give me as the parent or guardian only general information about coaching/counseling, except that the coach/counselor will tell
me if he or she finds out from my child or adolescent that they or others are in danger.
b. Families: At the start of family coaching/counseling all participants must have a clear understanding of any limits on confidentiality that may exist. The family must also specify which members of the family must sign Release of Information forms if necessary for the records of family coaching/counseling.
Acknowledgment: I understand that in family coaching/counseling, all members of the family must understand the limits of confidentiality and must agree on which family members will have the power to sign Release of Information forms authorizing disclosure of information about the family's history or treatment.
c. Couples: If one member of a couple tells a coach/counselor something the other member does not know, and not
knowing this could harm him or her, the coach/counselor cannot promise to keep it confidential from the other
person. If this occurs the coach/counselor will discuss it with you before doing anything else.
Acknowledgment: I understand that if I am in couple's coaching/counseling and tell the coach/counselor something my
partner does not know, and not knowing this could harm my partner, the coach/counselor and this agency cannot promise to keep that information confidential from my partner.
5. Group coaching/counseling: In group coaching/counseling, the other members of the group are not coach/counselors and, therefore, are not bound by the ethical rules and laws governing coach/counselors. To avoid problems in this area, it is this agency's policy to ask all members of coaching/counseling groups to agree to protect one another's confidentiality, and to remove from the group any member who does violate another member's confidentiality. Still, this agency cannot be responsible for such disclosures by other clients, and it may be better for you to discuss information you feel must be legally protected in an individual session with your coach/counselor than in a
coaching/counseling group session.
Acknowledgment: I understand that in group coaching/counseling I do not have the same degree of confidentiality in group coaching/counseling sessions that I have in individual sessions with my coach/counselor, and that other group members are not coach/counselors and are not bound by the ethical rules and laws governing coach/counselors. I agree to place myself in the hands of those around me and share what I need to share, freely, openly, and honestly. I will not share information shared within this group outside of the group.
6. Professional consultation:
Your coach/counselor may consult with a clinical supervisor or another colleague about your treatment. The other coach/counselor must give you the same confidentiality
as your coach/counselor. If this fellow coach/counselor is employed at this agency, no written authorization from you is required. If your coach/counselor discusses your case with a professional outside this agency, such as a coach/counselor who treated you in the past, he or she must get your written permission (a Release of Information form) first. If another professional asks your coach/counselor for information about you during or after your treatment, your coach/counselor cannot provide any information unless that other professional provides a Release of Information which you have signed authorizing your coach/counselor to provide that information.
Acknowledgment: I understand that my coach/counselor may discuss my history and treatment with other
coach/counselors for professional purposes, and that if these other coach/counselors are not employed at this same agency my coach/counselor must get my specific written permission in advance.
7. Legal proceedings:
If a judge orders your coach/counselor to provide information about your history or your treatment, the coach/counselor must do so.
Acknowledgment: I understand that if ordered by a judge, my coach/counselor must give the court whatever information about my case the judge rules to be necessary.
8. Debt collections: If you fail to pay for services as agreed, and other methods of resolving the problem fail, this agency may have to use a collection agency or other legal means to collect the fees you owe. The only information the agency would disclose for this purpose would be your name and address, the dates you received services, and the amount of your unpaid balance. Additional fees for these services may incur if used.
Acknowledgment: I understand that if I fail to meet my financial obligation to this agency and it becomes necessary to use legal means to collect my fees, the agency may disclose my name, address, dates of services, and balance due for this purpose.
9. Recording coaching/counseling: This agency will not record coaching/counseling sessions on audiotape or videotape without your written permission. If you give permission for such recording, you have the right to know who will see
or hear the recording, for what purpose(s) it will be used, and when it will be erased or destroyed.
Acknowledgment: I understand that my coaching/counseling will not be recorded on audiotape or videotape without my written permission.
10. Referring agencies and conditions of treatment : If you have been involuntarily referred for treatment by a court or a government agency such as a probation department or Child Protective Services, your treatment may include requirements that you comply with conditions including reporting of information about your coaching/counseling to the agency that referred you for treatment, or reporting to that agency if you appear to have violated laws regarding substance abuse or agency rules regarding satisfactory participation in this program. If such reporting requirements exist, your coach/counselor will tell you about them before you start coaching/counseling, and will notify you when making any such required reports.
Acknowledgment: I understand that if I have been involuntarily referred for treatment by a court or government agency, the conditions of my coaching/counseling may include mandatory reporting to the referring authority about my coaching/counseling and/or any violations I commit of laws regarding substance abuse or of agency rules regarding my conduct while in this program.
11. Independent disclosure by client: Any information that you share outside of coaching/counseling, willingly and
publicly, will not be considered protected or confidential by a court.
Acknowledgment: I understand that if I myself willingly and publicly disclose information about my
coaching/counseling, that information is no longer confidential or legally protected.
Our signatures here show that we have read, understand, and agree to the conditions presented above.