423 NEXT - College 1 on 1 Coaching Form

Our services aim to provide support and guidance to young people struggling with various challenges, including but not limited to addiction, mental health issues, and personal development in connection with their recovery struggles. We offer coaching and educational resources tailored to meet the unique needs of each individual. Our approach is holistic, focusing on physical, emotional, and spiritual well-being. We are dedicated to helping young people navigate these difficult times with compassion, understanding, and excellence.

While extensive efforts are made to provide accurate and helpful guidance, it's important to understand that the recovery leader's role is not that of a licensed counselor or therapist. Therefore, they cannot guarantee specific outcomes or be held liable for the decisions made by individuals based on the information provided. The guidance offered is intended to be supportive and educational, and while it may complement professional counseling or therapy, it is not a substitute for it. Individuals are encouraged to seek professional help for any significant mental health concerns or issues. By engaging with the services, individuals acknowledge and accept these limitations of liability.

While we strive to maintain strict confidentiality, there are certain circumstances where we may be required to disclose information, such as if there is a risk of harm to the individual or others. These include situations where there is suspected child abuse, elder abuse, or threats of harm to oneself or others. In such cases, we are obligated to report this information to the appropriate parties. We are committed to protecting your privacy and will only disclose information when absolutely necessary to ensure your safety or the safety of others.

It is the goal of 423 Communities to provide an environment in which our clients may place their trust and confidence. Confidentiality means communication with your recovery leader and any records pertaining to your identity or services received will be held in confidence. 423 Communities will maintain confidentiality to the fullest extent personally and professionally. You have a right to confidentiality. Please find attached our Confidentiality Policy and Privacy Practices. It is your copy to keep and states more fully our policies and practices and your rights therein. Please read our Confidentiality Policy and Privacy Practices before signing this agreement. If you believe the Confidentiality Policy and Privacy Practices document does not answer all your questions regarding confidentiality, talk with your recovery leader about any concerns you may still have. Your signature at the end of this document serves as your consent to use your personal health information for routine practices for consultation. You may revoke this consent in writing at any time, except to the extent that 423 Communities has taken action relying on this consent.

To be honest, open and willing to share your concerns. 2. To ask questions when you don’t understand or need clarification. 3. To discuss any reservations you have about your process. 4. To follow the agreed upon steps in the restoration journey to the best of your ability. 5. To report changes or unexpected events related to your problem. 6. To keep appointments whenever possible. When necessary to cancel or reschedule, to provide at least 24 hours notice.

Please retain this form for your records. 423 Communities is concerned about confidentiality. We believe a sense of safety and security is necessary to the process of healing in which our participants are engaged. It is the goal of 423 Communities to provide an environment in which our clients believe they can place their confidence and trust. Where federal and state law differs, we comply with the stricter standard to ensure that your right to confidentiality is respected at all times. Examples of disclosure allowances under federal and state law for treatment, payment and healthcare operations are as follows: The leader will disclose necessary information and notify authorities and other third parties when there is reasonable suspicion a minor child (under 18 yrs), an elder person (65 yrs and older), or otherwise dependent adult (any age) has been harmed. - The leader will disclose necessary information and notify authorities or other appropriate parties when the client has directly admitted serious and imminent suicidal threats. - The leader will disclose necessary information and notify authorities or other appropriate parties when the client has directly admitted harmful acts or threatened action that is serious, imminent and attainable against a clearly identified third person or persons. Client communication and records must be disclosed when ordered by the court. Exceptions to confidentiality are made in specified civil law cases such as disclosures relevant to a parent-child relationship, e.g. , in a divorce action. If a participant files a malpractice suit or a formal complaint with their licensing board against a leader, confidentiality is waived. If you believe we do not follow the stated intentions laid out in this document and/or you believe your right to confidentiality has been violated, please talk with your leader or the 423 Communities executive director.

Informed consent is a crucial part of our services. By engaging with us, you acknowledge that the recovery leader is not a licensed counselor or therapist. While they provide support and guidance based on their expertise and experience, this is not a substitute for professional counseling or therapy. You understand that the recovery leader will keep all information with your teen confidential to the extent permitted by law, but there are exceptions, such as suspected child abuse, elder abuse, or threats of harm to oneself or others, where disclosure may be required by law in congruence with local state laws of the minor. You also understand that the recovery leader may discuss your case anonymously for professional consultation purposes. By participating in our services, you voluntarily agree to these terms and understand the nature and limitations of the services provided.

The Recovery Leader may, at times, share personal experiences or insights (self-disclosure) as a helpful tool to enhance the coaching process. Self-disclosure is used judiciously and purposefully to provide empathy, normalize experiences, and facilitate understanding. It is not intended to shift the focus from you or replace your own journey of self-discovery.

Either party may terminate services at any time, for any reason, by providing written notice to the other party. In the event of termination, the Recovery Leader will work with you to ensure a smooth transition and provide referrals to other appropriate resources, if necessary. You are responsible for any fees incurred for services provided up to the termination date. The Recovery Leader retains the right to terminate services if, in their professional judgment, continued services are not beneficial or appropriate for you. In such cases, the Recovery Leader will provide a referral to another qualified professional, if possible.

Please list all members of your immediate family & non-family members living in the household: (Name, Relationship, Age, Gender)

Please type in "N/a" if this question does not apply.

I agree that by typing my name below, this is acting as my official signature.

I understand that 1 on 1 coaching sessions involve 1 hour of services between the recovery leader listed and myself for a 60 min. session. These services have a suggested donation cost of $65/session. If I am able I agree to pay this amount for each session my child receives.

I consent to engage in Zoom/Video Format Services (internet or telephone based) for coaching when agreed by me and the recovery leader. I understand that this includes the practice of 1 on 1 coaching with me, including mental health engagements, coaching, self-disclosures, recovery processing, education, and other services through the use an interactive audio, video, and/or data communications. The laws that protect the confidentiality of my information also apply to these mediums. I understand that there are risks and consequences from these mediums. These may include, but are not limited to, the possibility despite reasonable efforts on the part of the recovery leader that: that transmission of information could be disrupted or distorted by technical failures; and/or misunderstandings can more easily occur. In addition, I understand that Zoom/Video Format services and care may not have the same results nor be as complete as face-to-face service. I have read and understood the information provided above.

I do voluntarily agree to participate in the recovery coaching process as offered by 423 Communities my selected recovery leader. I am aware that this process often involves family engagement, participation, or education which will be recommended if the recovery leader deems it important to the healing process. This process can contain but is not limited to family of origin, core beliefs, deep shame, desires, etc. I acknowledge that no guarantees have been made to me regarding the outcome of my coaching process in these services. I understand my rights and responsibilities as stated in the document. I have read, understand, and discussed in detail any questions I have related to the 423 NEXT Coaching Process. I have read and agree to the suggested payment information as stated in this document. By my signature below, I accept all the terms and conditions as stated in this document.

We are pleased that you have chosen 423 Next to find hope, healing, and restoration. This form gives you some information about our professional relationship. You are encouraged to ask the recovery leader you selected and booked an appointment with any questions regarding their background, credentials, professional experience or philosophy. Please note that although our recovery leaders are extensively trained and equipped to provide coaching in these matters, the recovery leader is not a licensed therapist and these sessions are not governed by any state licensure board. As such, all fees associated with coaching are not submittable to any insurance provider.

I agree that by typing my name below, it is acting as my official signature.