Informed Consent

Hi Rock Stars!

Let’s start with the long, boring stuff! This information sheet has been prepared to acquaint you with the policies affecting issues that frequently arise over the course of coaching. Your agreement to this document, as well as the general Terms and Conditions and Privacy Policy, will indicate you have read, understood, and agree to its provisions. We are always willing to discuss our policies with you. I know, I know, it’s a lot of reading, and sounds a lot more serious than it is, but it won’t take long! THANKS!

Committing to Services

Confidentiality

Payment

Communication Policy

Text Messaging

At this time, Mindurance Now does not offer a text messaging platform, however a client and coach may choose to engage in text messaging as part of their coaching work together. That will be determined by the client and coach.

Email

Sending and receiving messages to/from the coach in the Mindurance Now dashboard will generate a email to the email account you provided. As such, be mindful of the following as it pertains to email:

Email can be immediately broadcast worldwide and be received by many intended/unintended recipients

Recipients can forward email messages to other recipients without the original sender’s permission or knowledge

Users can easily misaddress an email

Email is easier to falsify than handwritten or signed documents

Backup copies of email may exist even after the sender or the recipient has deleted his or her copy

Email containing information pertaining to a client’s concerns and/or treatment are included in the client’s file. Thus, all individuals who have access to the file will have access to sent/received messages.

Employees do not have an expectation of privacy in email that they send or receive at their place of employment. Thus, clients who send or receive email from their place of employment risk having their employer read their email.

If employers or others read an employees email and learn of coaching treatment, particularly references to mental health, sexually transmitted diseases, or alcohol/drug abuse information, they may discriminate against the employee/client. For example, they may fire the employee, not promote the employee, deny insurance coverage, and the like. In addition, the employee could suffer social stigma from the disclosure of such information.

Clients have no way of anticipating how soon Mindurance Now admin or coach will respond to a particular email message. Although Mindurance Now, its employees and coach will endeavor to read and respond to email promptly, Mindurance Now cannot guarantee that any particular email message will be read and respond to within any particular period of time.

It is the policy of Mindurance Now to make all email messages sent or received that concern coaching part of that client’s file and will treat such email messages with the same degree of confidentiality. Mindurance Now will use reasonable means to protect the security and confidentiality of email information. Because of the risks outlined above, Mindurance Now cannot, however, guarantee the security and confidentiality of email communication.

Thus, clients must consent to the use of email for confidential medical information after having been informed of the above risks.

Consent to the use of email includes agreement with the following conditions:

All emails to or from the client concerning coaching will be made part of the client’s file. As part of the file, Mindurance Now admin personnel, and other individuals outside this agency that you authorize through a release of information could have access to email messages contained in the file.

If the client sends an email to this coach, this coach will endeavor to read the email promptly and to respond promptly, if warranted. However, Mindurance Now can provide no assurance that the recipient of a particular email will read the message promptly. Because Mindurance Now cannot assure that recipients will read email messages promptly, clients must not use email in a medical emergency.

If the client’s email requires or invites a response, and the recipient does not respond within a reasonable time, the client is responsible for following up to determine whether the intended recipient received the email and when the recipient will respond.

Because some information is so sensitive that unauthorized disclosure can be very damaging, clients should not use email for in-depth communication. Mindurance Now will only use email for notifications of messaging, calling, billing, scheduling, and sending handouts and homework assignments when warranted.

Because employees do not have a right of privacy in their employer’s email system, clients should not use their employers email system to transmit or receive confidential medical information.

Mindurance Now cannot guarantee that electronic communications will be private. Mindurance Now will take reasonable steps to protect the confidentiality of client email, but Mindurance Now is not liable for improper disclosure of confidential information not caused by Mindurance Now’s gross negligence or wanton misconduct.

If the client consents to the use of email, the client is responsible for informing Mindurance Now of any types of information that the client does not want to be sent by email other than those set out above.

Client is responsible for protecting client’s password or other means of access to email sent or received from Mindurance Now to protect confidentiality. Mindurance Now is not liable for breaches of confidentiality caused by the client.

Any further use of email by the client that discusses diagnosis or treatment of the client constitutes informed consent to the foregoing. You may withdraw consent to the use of email at any time by email at admin@mindurance.org

Notice of Privacy - HIPPA

I have received in this packet and/or been offered a copy of Mindurance Now’s Notice of Privacy Practices (also posted on Mindurance Now website).

Social Media Policy

This coach will not knowingly send you a Facebook, Instagram, Twitter, or LinkedIn request, nor does this coach accept such requests to personal accounts from clients. Requests to the Official Mindurance profiles will be accepted, however it is the responsibility of the client to recognize that threats to confidentiality and privacy might occur as a result.

Telecoaching Services

Definition of Services:

Tele-coaching is the delivery of stress management and performance enhancement coaching services using interactive audio or audiovisual electronic systems where the coach and the client are not in the same physical location. The interactive electronic systems used in tele-coaching incorporate network and software security protocols to protect the confidentiality of client information and audio/visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

I understand that the coach currently offers tele-coaching via phone telecommunication.

Client Requirements:

I, the client, if receiving coaching services from a licensed practitioner (e.g., licensed psychologist, counselor, social worker) may require residency in the state that the coach is licensed in. This restriction will be identified by coaches in their profile bio and reiterated at the beginning of your first call. If I am receiving coaching services from any non-licensed coaches (e.g., CMPC), I am able to receive these services from any physical location.

Clients who are seeking psychological counseling or are actively at risk to harm to self or others are not suitable for tele-coaching services. If this is the case or becomes the case in the future, speak to your coach and more appropriate services will be provided or recommended.

Technology requirements:

I will need a computer, tablet, and/or phone with internet access and calling ability. Upon signing up for the online platform, a web call can be completed or I can call the system number directly using my mobile device.

Our technology service provider:

Mindurance uses a pay-per-minute calling technology and dashboard to fulfill services. This technology is HIPPA compliant and has been built to have messaging, document exchange, and billing functions that are efficient, effective, and secure. Client information will be stored on this secure site. Mindurance Now has reviewed this technology and its privacy and confidentiality standards are consistent with current standards. Please feel free to ask further questions if you have concerns.

Technology Failure:

I understand that in the event of a technology failure during a phone telecommunication session I will call back to the coach/extension. If issues continue, the coaching session may be rescheduled.

Recording of sessions:

I understand that Mindurance Now will not record my phone sessions, unless there is an explicit written consent by me for reasons that clearly benefit my treatment.

Emergency Protocol

I understand that in the event of an emergency and I will follow this emergency plan:

  1. Call 911 or local emergency response team
  2. Go to nearest emergency room
  3. Contact local crisis center

I understand that should a crisis occur while using the Mindurance Now platform, my coach will encourage me to follow the emergency plan. If I am considered a safety threat to myself or others, my coach will take steps to help ensure safety that include, but are not limited to, collecting telephone and address information from the Mindurance Now administration and notify the appropriate authorities.

Other:

Risks and Rights in using Tele-coaching:

I have the right to withdraw consent at any time. It will not affect my right to further treatment.

The coach has the right, at any time, to determine if tele-coaching sessions are not appropriate for my case. Should this be determined, they are obliged to provide referral information to other services.

Mindurance Now is committed to ethical, legal, and confidential safeguards. As such, Mindurance Now encourages its providers to apply the same laws and professional standards associated with psychological services to its tele-coaching services.

Despite best efforts to ensure high encryption and secure technology, there is always a risk that the transmission be breached and accessed by unauthorized persons.

There is a risk that services could be disrupted or distorted by unforeseen technical problems.

There is a risk of being overheard by anyone near me if I do not place myself in a private room. I, the client, am responsible for creating a comfortable and safe environment on my end of the transmission. It is the responsibility of the coach to do the same of their end.

Due to the nature of the interaction, there may be quality differences that are experienced when compared to face-to-face services. I may provide feedback to my coach should I find the quality insufficient for my needs.

I, the client, have received, reviewed and had ample opportunity to discuss the above tele-coaching policy.

I will comply with the above plans set up to address the potential risks of distance coaching and discuss any aspects that require my participation in the planning.

I have opted in for the electronic technology that is acceptable to me at this time.

I have had ample opportunity to ask questions and receive clarification about tele-coaching and this policy

I understand that I have the option to change my mind about any of my choices listed above and I will do so in writing

I do recognize the potential risks of compromise to my confidentiality by using phone or telecommunication

I wish to proceed knowing these risks.

THANK YOU SO MUCH! PLEASE LET MINDURANCE KNOW IF YOU HAVE ANY QUESTIONS!