COACHING INFORMED CONSENT AND DISCLOSURE DOCUMENT

SHANA GRAHAM – SEXUAL WELLNESS & RELATIONSHIP COACHING

Coaching is a partnership toward a common goal that relies heavily on honesty and trust. This document is designed to establish those qualities by disclosing your rights and responsibilities to the coaching relationship, and by informing you as to what you can expect from me.

Somatic (body-based) coaching differs from many other kinds of coaching work and therapy in that it emphasizes your connection to your body. It also emphasizes the importance of experiences (as opposed to thoughts) as the central vehicle towards deeper freedom and choice.

While the focus of our work together is the improvement of your sexual and relational lives, there may be other areas of your life (i.e. work, school, family history, etc.), which inform your sexual and relational well-being. We may need to discuss these and other realms to help you move through relationship and intimacy challenges.

Coaching is different from therapy. Although both coaching and psychotherapy use knowledge of human behavior, motivation and behavioral change, and interactive counseling techniques, the focus of coaching is the development and implementation of strategies that help people reach their identified goals of enhanced performance and personal satisfaction. This agreement is for coaching.

In the capacity of Sexual Wellness & Relationship Coach am NOT working as a licensed therapist, and I am not required to be licensed to practice sex & relationship coaching in the State of Washington. Limits of my practice include: I cannot diagnose organic or medical conditions of any nature, or prescribe medications for same. I also cannot offer diagnoses for mental health conditions. If you need additional support from a practitioner with expertise in those areas, I would be happy to help you find someone.

MY RESPONSIBILITIES TO YOU AS YOUR COACH

1) CONFIDENTIALITY

You have the absolute right to confidentiality in our work together. I will not tell anyone else what you have told me, or even that you are working with me, without your prior written permission. I will always act to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with whomever you choose, and you can change your mind and revoke that permission at any time.

If you elect to communicate with me by email or text message at some point in our work together, please be aware that these media are not completely confidential. All messages are retained in the logs of your and my Internet service provider, and text messages are recorded by your and my phone service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service or phone provider.

While coaching does not fall under the same mandated reporting requirements as therapy, I reserve the right to break confidentiality if I believe that you are likely to cause harm to yourself or someone else. I will inform you of any time when I think I will have to do so.

I have consulting or supervisory relationships with several experienced relationship coaches and it is common practice for me to consult with them on my caseload. I also sometimes consult with other coaches to seek their input so that I can provide the best services possible. The only purpose of consultation is to ensure quality of care. I make every effort to protect your identity at all times in these settings.

2) RECORD KEEPING

I prefer to take some notes during and after our sessions, and retain them in your records, for both your protection and mine. In the state of Washington, you have the right to request that I not keep any detailed records. If you would like to exercise this option, please let me know, and I will present you with a written request to sign.

All reasonable precautions are taken to secure your records, and they are strictly confidential, with the following exceptions:

a) Records are released with your written authorization, or that of your personal representative, should you become disabled or die.

b) Records are released if you waive privilege by bringing charges against me.

c) Records are released in response to a subpoena from the state secretary, in response to a regulatory investigation, and as required in cases of abuse, neglect, or harm to self or others.

3) TOUCH, CONSENT, AND OUR WORKING RELATIONSHIP

During our work together, there may be times when I invite you to experiment with yourself, your partner(s), or with me around emotions, touch, intimacy, and connection—all within the express boundaries of my Somatica training. All of these experiments are in service of you having a deeper understanding of your own internal process. Touch is only used with your informed consent, and only when you actively say yes. I will take silence, saying “maybe,” or any response other than a clear “yes” as a “no.”

Before we engage in any touch-based practice, I will describe and explain what I’m suggesting so that you can make an informed choice about exploring it, and so we can make any adjustments needed to make the exercise both safe and effective. You have the right to stop or change any touch or exercise in which we are engaging AT ANY TIME, for any reason. I will respond to your expressed boundary request respectfully and without question. I also watch for non-verbal cues and reserve the right to check in with you or stop an activity or exercise when I feel it is not serving you or potentially causing harm.

In order to maintain the container that supports the personal growth and healing work that we will engage in, we will not have any personal relationship while we are working together, and for at least one year after the termination of our coaching relationship. In this context, “personal relationship” includes close friendship and intimate social interactions. You are welcome to follow or interact with me on social media and/or to attend events I host, with the understanding that it does not constitute a personal relationship.

Since I sometimes share social community with clients and I produce events and workshops, it is possible that we might both be present at the same event or in the same social spaces, or have mutual acquaintances. If we see each other in public or social spaces, I will not acknowledge that you are my client or anything related to our work together and I will greet and interact with you as I do any other community member. You are welcome to acknowledge or divulge our practitioner-client work together or not, as you choose.

Navigating Pre-Existing Relationships

If you and I share professional circles, we will have an open and frank discussion before our first coaching session to talk about what we would each need to both support our work together and maintain an appropriate professional relationship.

If you and I have a pre-existing personal or professional relationship, we will have an open and frank discussion to explore if we can maintain our connection, if we need to shift entirely to a practitioner-client relationship, or if you would be better served by a different coach. That will depend on the nature of the concern or topic that you are seeking support for, the history that we share, and your motivations or approaching me. Your safety and needs will be prioritized through this process.

YOUR RIGHTS AS A COACHING CLIENT

You have the right to ask questions about anything that happens as part of our coaching work. I'm always willing to discuss how and why I've decided to do what I'm doing, and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful, so we might discuss my level of experience with the technique you have in mind. You can ask me about my training for working with your concerns and can request that I refer you to someone else if you decide I'm not the right practitioner for you.

You are free to end coaching at any time, for any reason. Usually, it will be up to you to decide when to discontinue working together. If, in my professional opinion, I am no longer serving your best interests for any reason, including an exceeding of my competence, I will refer you to another qualified professional. If you do violence to, verbally or physically threaten, or harass my family or me, I reserve the right to terminate you unilaterally and immediately from coaching. If I terminate you from coaching, I will offer you referrals to other sources of care but cannot guarantee that they will accept you as a client.

You have the right to refuse treatment and the right to choose a practitioner and treatment modality that best suits your needs.

YOUR RESPONSIBILITIES AS A COACHING CLIENT

1) ATTENDANCE

You are responsible for coming to your session on time and at the time we have scheduled. If you are late, we will end on time and not run over into the next person's session. If you miss a session without canceling, or cancel with less than 48 hours’ notice, you must pay for that session before our next regularly scheduled meeting. The only exceptions to this rule are if you would endanger yourself by attempting to come (for instance, driving on icy roads without proper tires), or if you are having a genuine emergency. I reserve the right to assess the nature of your situation, determine whether it is a true emergency, and decide whether it qualifies as an exception to this policy.

2) ALTERED STATES

Coaching with me involves working together to help you access, observe, and process deeply emotional content as a resource for insight. You are responsible for coming to sessions “unaltered.” I have no judgment about your recreational activities outside of our time together, but the presence or residue of any drugs, alcohol, or the like in your system challenges our ability to reach those deep emotions in a way useful to our purpose. You will also not be permitted to use any substances by any means of delivery while in session. “Substances” include, but are not limited to alcohol, nicotine, marijuana, benzos, narcotics, and psychedelics/hallucinogens. UNLESS substances are PRESCRIBED BY A MEDICAL PROFESSIONAL, and taken as prescribed, you will be asked to reschedule your session should your altered state become apparent. You will be charged full fee for the session.

3) RATES

My regular fee is $150 for a 60-minute session and $225 for a 90-minute session. Other sessions lengths are possible and rates will be set for them at a prorated basis. I also offer packages of sessions at discounted rates.

Fees for other professional services (such as treatment coordination and/or consultation with other Practitioners or individuals, telephone contact in excess of 15 minutes and telephone, Skype or email counseling) are prorated based on the usual session fee. Fees for existing clients may be adjusted at the beginning of each calendar year. You will be informed in advance of any fee increases.

I maintain a limited number of sliding scale spots on my schedule for clients who are experiencing financial need. Please reach out if this applies to you and we can discuss finding a way to make coaching accessible to you.

4) PAYMENT

You are responsible for paying for your session before or at the time of service, unless we have made other arrangements in advance. I prefer to take payment via PayPal (https://paypal.me/ShanaGraham) or Venmo (https://venmo.com/supershana). You can also pay via credit card on my website. I can also accept cash or personal checks if you’re seeing me in-person.

You will be surcharged $25.00 each for the first two checks returned for insufficient funds; thereafter, I will not accept your check. I am not willing to have clients run a bill  with me. I cannot accept barter for coaching, nor can I take DSHS medical coupons. Any overdue bills will be charged 1.5% per month interest.

I am not part of any in-network insurance panels and you should not expect any of the services to be covered or reimbursed by insurance or through a flexible spending account. You assume full responsibility for and agree to pay all costs, charges, and expenses or services rendered under this Agreement.

5) COMPLAINTS & CONCERNS

There are no guaranteed results in coaching. If you're unhappy with what's happening in our work together, I hope you'll talk about it with me so that I can respond to your concerns. I will always take such feedback seriously, and with care and respect.

6) HEALTH; CONSENT TO TREATMENT

By accepting the terms of this Agreement, you voluntarily consent to coaching, treatment, or evaluation performed by me, with the understanding that I am not a licensed therapist. This consent for treatment is valid for all services that are provided from the date that you sign this Agreement until services are terminated. You understand that you can revoke this consent for treatment at any time in writing (an email can serve this purpose) to me.

You represent that you are physically and mentally sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent you from receiving the services or that would risk your health or well-being while receiving the services. You agree to notify me of any changes in mental or physical health or life circumstances that may affect your treatment.

7) ASSUMPTION OF RISK; LIMITATION OF LIABILITY

You certify that you voluntarily agree to receive these services. You understand and acknowledge that sex and relationship coaching, by its very nature, carries with it certain inherent risks that cannot be eliminated. You understand and acknowledge that, regardless of the care taken by me, I cannot guarantee your safety, health or well-being, or any specific results. You expressly assume and accept sole responsibility for your health and safety and for any and all injuries that may occur. You understand that you must inform me of any medical conditions, medications or other factors that may affect your ability to safely receive the services.

You agree that to the fullest extent permitted by law, I shall not be liable to you for any injury, harm, loss or damage that you may suffer as a result of your receiving the services or of any activity contemplated by this Agreement. You hereby agree to waive any claim against me for any injury, harm, loss or damage that you may suffer as a result of your receiving the services or of any activity contemplated by this Agreement.

8) INDEMNIFICATION

You agree to hold harmless and indemnify Shana Graham Coaching and Neverland LLC from all claims (whether initiated by you or by a third party) and to reimburse them for any expenses incurred as a result of your involvement with me or receipt of my services.

9) TREATMENT REFUSAL/TERMINATION

You acknowledge that you have been informed that at any time you can suspend or refuse to implement any and all recommendations or instructions made by me. You agree to maintain awareness of and keep all of your physical and emotional boundaries. Additionally, you will inform me within a reasonable time if anything happens during a session that makes you feel uncomfortable.

The ongoing commitment to the relationship between you and me will always be treated with utmost importance. I will make every effort to maintain a mutually healthy working relationship and I ask you to do the same. That being said, either your or I are free to terminate this agreement at any time, for any reason. If you would like to continue coaching or start some form of therapy with a different practitioner, I will make every effort to assist with that transition.

10) ACKNOWLEDGEMENT

By accepting this Agreement, you acknowledge that you have carefully read it and understand that includes a complete and absolute release of liability. You agree that you have knowingly agreed to receive the services and that you have been given an opportunity to ask questions regarding the Agreement and the services.