Homayoun Shahri, Ph.D., M.A., CBT, MFT86676
4199 Campus Drive, Suite 550, Irvine, CA 92612
(You may also download this form, print it, fill it out, and bring it with you to the office - Download)
4199 Campus Drive, Suite 550, Irvine, CA 92612
(You may also download this form, print it, fill it out, and bring it with you to the office - Download)
Life Coaching Consent and Life Coaching Contract
1- The Life Coaching Process
Participating in life coaching can result in a number of benefits to you, including the better understanding of your personal goals and values, improved interpersonal relationship, and resolution of the specific concerns that led you to seek life coaching. Working toward these benefits, however, requires effort on your part and may result in your experiencing considerable discomfort. Change will sometimes be easy and swift, and more often it will be slow and frustrating. Remembering unpleasant events and resolving them through life coaching can bring on strong feelings of anger, depression, fear, etc. Attempting to resolve issues between marital partners, family members, and other individuals can also led to discomfort and may result in changes that were not originally intended.
2- Client’s Rights
You have the right to confidential relationship with me. Within certain legal limits (see #3 below), information revealed by you during the course of life coaching work will be kept completely confidential and will not be revealed to any person without your written permission.
As life can bring unexpected circumstances, should I be unable to continue your life coaching, one my trusted colleagues will contact you to discuss what would be best for you at that time.
Fees & Financial Responsibilities
Consent for Life Coaching
I understand that the purpose of any procedure will be explained to me and be subject to my agreement. I have read and fully understand this Consent for Life Coaching form.
Office Policies
Cancellation: A minimum of 24-hour notice is required for rescheduling or cancellation of an appointment. A fee of $50 will be charged for sessions missed without such notification.
Office Hours: My office hours are from 9:00 a.m. to 6:00 p.m., Tuesday through Thursday and Saturday. If you need to contact me between sessions, please leave a message at (949) 391-7790 and I will return your call.
Copy of Records: If you need a copy of your records you must give us 10 working days advanced notice to copy the material for you. There is a $0.20 per page cost for copies.
Emergency Procedure: A clinical emergency is an unexpected not life threatening event that requires immediate attention and can be a threat to your psychological health. If a clinical emergency situation arises, please call my cell and follow the instructions on the voice message system. In case of medical or life-threatening emergencies, please call 911 and do not leave a message for the office.
1- The Life Coaching Process
Participating in life coaching can result in a number of benefits to you, including the better understanding of your personal goals and values, improved interpersonal relationship, and resolution of the specific concerns that led you to seek life coaching. Working toward these benefits, however, requires effort on your part and may result in your experiencing considerable discomfort. Change will sometimes be easy and swift, and more often it will be slow and frustrating. Remembering unpleasant events and resolving them through life coaching can bring on strong feelings of anger, depression, fear, etc. Attempting to resolve issues between marital partners, family members, and other individuals can also led to discomfort and may result in changes that were not originally intended.
2- Client’s Rights
You have the right to confidential relationship with me. Within certain legal limits (see #3 below), information revealed by you during the course of life coaching work will be kept completely confidential and will not be revealed to any person without your written permission.
- You have the right to know the content of your records at any time, and I have the right to provide you with either the complete records or a summary of their content.
- If you ask me, I can release any part of your records on file with me to any person you specify. I will tell you when you make your request whether or not I think releasing that information to that agency or person might be harmful to you at any time.
- Under certain legally defined situation, I have the duty to reveal information you tell me during the course of coaching to other persons without your written consent. I am not required to inform you of my actions if this occurs. These legally defined situation include: A) If you reveal information to me about active child abuse or neglect, elder abuse, or dependent adult abuse, I must make a report to protective services. When a perpetrator of child abuse is in contact with minors and there is a reasonable suspicion that he/she may still be abusing minors, I must also report that information. B) If you seriously threaten to harm another person, I am required to warn the intended victim and notify the appropriate law enforcement agencies.
- You have the right to ask questions about any of the procedures used in the course of your life coaching. If you ask, I will explain my customary approach and methods to you.
- You have the right to choose NOT to receive life coaching from me. If you choose this, I will provide you with names of other qualified professionals whose services you might prefer.
- You have the right to terminate life coaching with me at any time without financial, legal, or moral obligations other than those you’ve already incurred. I have the right to terminate life coaching with you under the following conditions: A) When I believe that life coaching is no longer beneficial to you. B) When I believe that you will be better served by another professional, whom I will recommend. If I determine during the first three sessions that I cannot help you, I will assist you in finding someone qualified. If you have written consent from you, I will provide that professional with the essential information she or he requires. C) When you have not paid for the last two sessions, unless special arrangements have been made with me. D) When you have failed to show up for your last two life coaching sessions without a 24-hour notice of cancellations.
As life can bring unexpected circumstances, should I be unable to continue your life coaching, one my trusted colleagues will contact you to discuss what would be best for you at that time.
Fees & Financial Responsibilities
- I agree to enter life coaching with Dr. Homayoun Shahri. I also agree that, I am responsible for paying my bill in full. I also agree that I will pay the agreed upon fee as indicated below every session.
- I will make payment by cash, check, or credit card at the starting time of the life coaching appointment. I am contracting only to pay for completed life coaching sessions. I will pay $50 for sessions I miss without providing 24-hour notice and the telephone time as outlined in the Part V of this contract.
Consent for Life Coaching
I understand that the purpose of any procedure will be explained to me and be subject to my agreement. I have read and fully understand this Consent for Life Coaching form.
Office Policies
Cancellation: A minimum of 24-hour notice is required for rescheduling or cancellation of an appointment. A fee of $50 will be charged for sessions missed without such notification.
Office Hours: My office hours are from 9:00 a.m. to 6:00 p.m., Tuesday through Thursday and Saturday. If you need to contact me between sessions, please leave a message at (949) 391-7790 and I will return your call.
- Telephone Time: After 10 minutes of telephone time, you will be charged at your regular prorated fee for the total time of the phone contact.
- Sessions Greater Than 45 Minutes: Sessions that go beyond 45 minutes will be prorated to the nearest quarter hour.
Copy of Records: If you need a copy of your records you must give us 10 working days advanced notice to copy the material for you. There is a $0.20 per page cost for copies.
Emergency Procedure: A clinical emergency is an unexpected not life threatening event that requires immediate attention and can be a threat to your psychological health. If a clinical emergency situation arises, please call my cell and follow the instructions on the voice message system. In case of medical or life-threatening emergencies, please call 911 and do not leave a message for the office.