Welcome!

I look forward to partnering with you to create a more peaceful and joyful family dynamic.

Please complete this intake form which includes the Family Coaching Agreement and HIPAA disclosure prior to our first session.

Once this is taken care of, we can focus on our work together and improving your emotional wellbeing and family life.

With gratitude,

Dr. Cam

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* 1. Contact Information

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* 2. Please provide the names of all immediate family members. Include the age(s) of your child(ren).

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* 3. What is the biggest challenge you are currently facing regarding your teenager(s) right now?

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* 4. What obstacles are preventing you from resolving this challenge?

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* 5. If I could solve one problem that would "change everything" for you as a parent, what would it be?

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* 6. Anything else you'd like me to know?

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* 7. Which coaching program are you participating in?

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* 8. How did you hear about my services?

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* 9. FAMILY COACHING CONTRACT

This Agreement is effective as of the date signed and will continue during the course of our work together.

My commitment to you: By agreeing to meet with you, I am committing to meeting at the time(s) we have agreed upon and providing a safe setting within which we can explore issues and difficulties and move towards change. I want the very best for you and will do everything I can to help you achieve your goals. I promise to support and encourage you while you do the work and celebrate with you as you reap the benefits of your efforts.  

Certain situations including emergencies and crises are inappropriate for traditional family coaching services. If faced with a crisis or emergency, I strongly encourage participants to immediately call 911 or seek help from a mental health professional or health care facility. This includes but is not limited to: thoughts about hurting or killing either another person or yourself; hallucinating (seeing or hearing things others don't: having delusions (beliefs others may consider unrealistic); encountering a life-threatening or emergency situation of any kind; abusing or having an addiction to alcohol or drugs; suicidal thoughts or attempts (National Suicide Hotline Toll-Free Number: 1-800-784-2433).

Your commitment to you: In agreeing to participate in the 8-week coaching program with Dr. Cam, you are committing yourself to complete the full process. This includes joining all sessions at the agreed-upon time and optimizing the use of the time we have together. Being honest and objective; ready to work and receive feedback; intent and open to change; and willing to explore and challenge your thoughts, feelings, and actions that are self-defeating are essential to improving your mindset and relationships. Please inform me immediately when things are not working for you or make you uncomfortable so we can adapt.  

No guarantee of results: Although I am the facilitator of change, I cannot force you or your children to take action. Your progress and end results are dependent on your participation and commitment to the process.

Payment policy: Payment is due before or on the day of service.  

Refund policy: You can receive a full refund if requested BEFORE the 8-week program has begun. However, after the first session of the 8-week program has occurred, there are no refunds. It is your choice to complete the program or relinquish the time we have left. Sessions do not expire, so you do have the option of putting the process on hold.

Scheduling and cancellation policy: You will have access to my calendar to schedule, reschedule, and cancel your appointments. I reserve the right to cancel and reschedule coaching sessions as needed and will provide as much notice to you as possible. If you need to reschedule, please give me at least 12 hours advance notice. If sessions are missed without at least 12-hrs. notice, you will be charged the full session fee.

Dr. Cam Consulting, LLC reserves the right to refuse service for any reason.

Confidentiality and recording consent: You agree to the attached Confidentiality and HIPAA Disclosure Consent. You also consent to allow me to record via writing during all Family Coaching Sessions. 

Release of liability: You acknowledge that Family Coaching is not provided in lieu of other professional medical services. You agree that utilizing Family Coaching is entirely at your own risk. Any actions or lack of actions, taken by you based on such advice is done so solely by choice and up to your discretion.

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* 10. Confidentiality and HIPAA Consent

This Confidentiality and HIPAA Consent (this “Consent”) is entered into in conjunction with the Dr. Cam Consulting, LLC Agreement (the “Agreement”) between me, the Family Coach (“Dr. Cam,” “I,” “me”), and you, the client (the “Client,” “you,” “your”). The Client and Dr. Cam are referred to as the “Parties” (or “our,” “we”).

In Essence
I recognize that in the course of our work together, you may disclose the following: future plans, health information, financial information, job information, goals, personal information, and other proprietary information. I will not at any time, either directly or indirectly, use any information for my own personal benefit. I will never disclose, or communicate in any manner, any of your information to any third party.

Since I am a Family Coach, you are giving me permission to discuss our conversations with my colleagues. However, I will never use information that would identify you without your consent. I will limit your identifying information to gender and age only.

Furthermore, I will not divulge that you and I are in a coaching relationship without your permission. I will hold everything that we say and do confidential unless you present as a physical danger to yourself or others. In this case, I will inform legal authorities so that protective measures can be taken.

Confidentiality
Any information you disclose to me in connection with Family Coaching (as defined in the Agreement) will be kept strictly confidential in accordance with the following terms and conditions.

HIPAA Notice of Privacy Practices
HIPAA requires me to safeguard your protected health information (PHI) which includes any information that could reasonably identify you, including data about health conditions and the Coaching Services. Under HIPAA, I may use and disclose your PHI for the following reasons:

Treatment: To coordinate care, and with your signed consent, I may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who are involved with your care.

Obligatory Disclosures: Exceptions to confidentiality include child abuse and neglect reporting statutes, medical neglect of children and the elderly, elder abuse in the community or in nursing homes, and domestic violence. The Family Coach may disclose PHI in certain legally required circumstances.

Additional, Optional Disclosures
By signing this Confidentiality and HIPAA Disclosure Agreement, you consent to the following additional disclosures:

Marketing Purposes: For marketing purposes, with your consent, I may use and publish any testimonials, reviews, quotes, or other communications regarding the Family Coaching made by you. I will not share any details related besides the fact that you engaged with a Family Coach.

Communication Platform: You and I may communicate between a variety of communication platforms including, phone, video, or e-mail. These platforms may not be secure or HIPAA compliant. You consent to using non-HIPAA compliant platforms for our communications.

Revocation of Written Authorization
By signing below, you agree to the above authorizations. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing to stop any future disclosures.

Complaints
If you feel I have violated your privacy rights or if you object to a decision I have made about access to your PHI, you are entitled to file a complaint. First and foremost, notify me directly if you feel I have violated your rights. You can also file a complaint with the U.S. Department of Health and Human Services Office.

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