By signing this Agreement, Client and Client’s Parent(s) engage WCP to provide behavioral coaching services, which may include executive functioning, life skills, and/or parent coaching services (the “Services”).
Client and Client’s Parent(s) understand that the Services will be provided by a behavior coach (the “Coach”) that is contracted with or employed by WCP. The Parties understand that the Coach is not a licensed mental health professional (i.e., a licensed psychologist, social worker, marriage and family therapist, professional counselor, or addiction counselor) and that the Coach does not provide therapy, psychotherapy, or professional mental health services.
All Client Services are by appointment only and are conducted either in the Client and Parent(s)’ home, the Client’s School, at WCP office(s), or by phone/video conferencing. Client and Parent(s) are expected to be available, prepared, and on time for all appointments. Appointments may end at the scheduled time whether Client was on time or not and will not be prorated if Client is late.
Client and Parent(s) agree to pay WCP at the fee of $200/hour for the Services. Client and Parent(s) agree to contact WCP at least 24 hours ahead of time to cancel an appointment. Without this notice, Client and Parent(s) will be charged in full for the appointment.
WCP also bills at the standard hourly consultation rate of $200/hour for “collateral” work outside of coaching sessions, including:
· Face-to-face time spent with clients or parents outside of regularly scheduled Services.
· Services-oriented phone calls and email communications with clients, parents, teachers, or other providers greater than 10 minutes in length or time to complete.
· Writing e-mails to summarize Services for clients or parents.
· Attendance at school meetings or other professional settings.
· Completing documentation needed for other providers (e.g., applications for other services) and/or reviewing documentation provided by clients, parents, or other providers (e.g., our review of IEP documents, etc.).
All appointments for a given month will be billed for at the end of that month in accordance with WCP’s internal billing procedures. Client and Parent(s) shall timely pay such invoices in accordance with the instructions on the invoice. Client and Parent(s) understand and agree that WCP may suspend or terminate the Services, without liability, for any Client who has not paid in full within 30 days of when an invoice is due. Parent(s) and Client agree to the fee set forth above, and agree to pay all fees for Client in accordance with the terms of this Agreement.
Client and Parent(s) understand that most insurance companies and health plans do not cover or pay for the coaching Services contemplated under this Agreement. WCP does not bill insurance companies for the coaching Services and all Clients are self-pay and pay out-of-pocket for the Services. WCP will directly bill the Client for the Services provided by the WCP Coach. By signing this form below, Client and Parent(s) understand, agree, and accept that they will be financially responsible for all charges billed for the coaching Services provided under this Agreement.
Client and Parent(s) understand and agree that WCP may use and disclose Client’s health information to the Coach in accordance with WCP’s Notice of Privacy Practices, which are publicly available on WCP’s website. All such health information, and any health information received or requested from third parties, will be maintained in accordance with the WCP Notice of Privacy Practices and WCP’s privacy policies and procedures.
You acknowledge, and by signing this form, agree that neither you nor the coach will record (audio or video) any sessions without the prior mutual written consent of the coach and client.
Coaching Process and Disclaimer
A. Coaching is designed to support the development of the Client’s executive functioning skills and behavior within the family and/or school environments and with the support of Parent(s). Client and Parent(s) agrees to communicate honestly, be open to feedback and assistance and create the time and energy to participate fully in the coaching program. However, due to the subjective nature of the work, Client and Parent(s) understand and agree that WCP makes no guarantee as to the results Client will achieve, nor is WCP responsible for the results achieved by Client through the program.
B. Client and Parent(s) understand that coaching is not counseling, therapy, or psychotherapy, is not a substitute for counseling, therapy, or psychotherapy if needed, and does not prevent, cure, or treat any mental or physical health disorder.
C. Parent(s) understand the nature of behavior coaching and hereby authorize the WCP Coach to work with Client through the WCP behavioral coaching program.
Should a dispute arise out of this Agreement that cannot be resolved by mutual agreement of the Parties, the Parties agree to resolve the dispute by negotiating in good faith for 30 days after written notice of the dispute is given to the other Party pursuant to the Notice provision below. If the dispute is not resolved, and in the event of legal action, the prevailing party shall be entitled to recover attorney’s fees and court costs from the other Party.
Client and Parent(s) agree and understand that emergency medical or mental health issues must be addressed directly by Client’s doctor or licensed mental health professional, or by accessing emergency 911 services if warranted. Client’s Coach should be informed of the emergency as a point of information only and only after Client and/or Parent(s) have contacted the appropriate emergency professionals listed above.
All notices, requests, demands or other communications hereunder must be in writing and must be given, and shall be deemed to have been given, upon receipt if delivered by Federal Express, on the date of delivery if delivered in person, or three (3) days after mailing if sent by certified or registered mail with first-class postage prepaid, as follows:
If to WCP:
Wolff Child Psychology, PLLC
3345 W. 38th Avenue
Denver, CO 80211
If to Client/Parent(s):
Address listed in signature block below
Terms and Termination of Services
The terms of this Agreement shall be on a month-to-month basis, and will automatically renew under the same terms and conditions unless otherwise terminated by any Party by providing prior written or e-mail notice to the other Party. WCP will refund any advance payments made for coaching services not yet rendered in accordance with the terms of the Agreement. Client and Parent(s) understand and agree that fees paid for services rendered or appointments canceled without required notice are not refundable. This Agreement may be amended upon mutual written agreement of the Parties.
Complete Agreement and Choice of Law
This Agreement constitutes the entire agreement of the Parties, and reflects a complete understanding of the Parties with respect to the subject matter and supersedes all prior written and oral representations, communications or agreements. The Parties agree that this Agreement shall be deemed to have been signed and performed in the state of Colorado; and the laws of the state of Colorado will control this Agreement without regard to its conflicts of laws provisions.