AGREEMENT FOR ASSESSMENT
Please read the following agreement and fill out the below form as soon as possible (no later than 24 hours prior consultation). Be as accurate and descriptive as you can; the more information you provide me with at this time, the better the collaboration for us to achieve your goals. Return the agreement as an attachment to firstname.lastname@example.org.
Thank you and I will be looking forward to start your journey.
AGREEMENT FOR COUNSELLING/COACHING & HEALTH ASSESSMENT FOR TARGETED WEIGHT MANAGEMENT SERVICES
The purpose of this agreement is to set out clearly the arrangement for health assessment, dietary planning, and counselling/coaching services related to health and weight management (the ‘Service’) between the Client, (‘you’), and Transformative Health Coaching (‘Me/I/We’). This agreement gives us the opportunity to set out, from the start, a description of the therapeutic process, mutual commitments, costs and timescales.
It also sets out rules governing the counselling, and the boundaries that will apply during the period the Service is being provided.
At all times, the counselling or therapy we offer, and the terms of this agreement, will be consistent with the code of ethics published by PACFA (the Psychotherapy and Counselling Federation of Australia).
2. Aim of our Consultations
The aim of our consultations is to provide you with a confidential opportunity to explore your personal and specific issues relating to weight management and your eating and exercise habits. The role of Transformative Health Coaching is to help you through this process without judgement and to guide you with the what and the how of diet and exercise regimes designed to support the achievement of your goals. We will work with you to identify and set these weight goals and may on occasions, give information and offer suggestions and/or instructions during these consultations to move you towards your goal.
At any time when we believe you will benefit from the services of other health practitioners, such as Physiotherapists, Exercise physiologists, GPs or even another mental health professional, we will offer to refer you to those practitioners to address your needs if you do not have access to your own specialists/health practitioner, subject to your agreement.
3. Our commitment to you during consultations
Throughout the Consultation Period, we will:
Engage in direct and personal conversations either face-to-face or by telephone/video conference, as jointly agreed with you
Where a goal or vision is clear, we will hold that goal/vision as the context for the consultations
Seek permission before discussing deeply personal or sensitive topics, and before entering into any deep reflective processes with you
Provide a safe, yet challenging awareness raising environment for you to promote exploration and discovery to help you overcome challenges to achieving your goal
Employ assessment of your physical health and use reflection, visualisation, journaling, use of images and other techniques that help connect the body to the conscious and subconscious mind of the Client
Take a holistic, integral approach to our services to transform both your body and mind to ensure sustainable results
Seek feedback from you and review your progress achieved against the goals.
4. Our request of you
Throughout the Consultation Period, we request that you:
Demonstrate a willingness to be actively involved and committed to your goals and the coaching process
Always seek clarifications or information to make sure your consent to our Services is an informed one
Be responsible for your own self-care and say if any aspect of our session/approach is not working for you
Give permission to us to challenge and confront thinking, behaviours and feelings during the sessions in support of deepening self-awareness and achieving your health goals
Honour any agreements to keep journals or diaries or follow-up actions that are agreed as part of the consultation sessions.
To ensure open exploration of the goals and concerns that have brought you to our Service, Transformative Health Coaching maintains confidentiality in accordance with Psychotherapy and Counselling Federation of Australia (PACFA) Ethical Framework for Good Practice in Counselling & Psychotherapy (Code of Ethics).
We protect our Clients’ privacy and confidentiality. We will inform you of the confidential nature of our services and explain the limits to confidentiality. Our Client’s right to confidentiality continues after the Client’s death unless there are overriding legal considerations.
We will take into account the legal obligations and the Clients’ rights under privacy legislation and any other legal requirements relating to privacy.
We will not disclose personally identifiable and sensitive information about you (the Client) and take steps to prevent unauthorised disclosure. Disclosure may be authorised in the following circumstances:
a. by client consent; or
b. where there are risks to the safety of the client or the safety of a third party (if the
circumstances are serious enough to justify disclosure); or
c. when required by the law, and even then, we will redact the pertaining information we see relevant to disclose; or
d. If you share information about a proposed act of terrorism or other illegal acts.
When making an authorised disclosure of a Client’s personal information, we will inform the Client of the actions we will take, to the extent that this is practicable. If possible, we will obtain the Client’s consent in writing prior to making the disclosure.
We protect the confidentiality of client records using a secure storage system, either for paper or electronic records as appropriate.
6. Consultation Period and session duration
Our Consultation Period begins as a package of three (3) initial consultation sessions, focused on conducting a comprehensive health assessment to review and gather a baseline of your bio-medical information, understand your diet and exercise habits and preferences, agree your health/weight goals, and create your customised diet and exercise plan.
Initial sessions last approximately 50 minutes held at weekly/fortnightly intervals.
All follow-up sessions thereafter will last approximately 50 minutes at mutually agreed intervals tailored to suit your personal circumstances and customised diet and exercise plan. Session duration may be extended by mutual agreement should circumstances dictate at an additional fee. All follow up sessions will be on a pay-as-you-go basis.
Our prescribed Consultation Period is based on a total of 10 sessions (3 x initial plus 7 x follow up sessions) for our Clients to see real and lasting results. We ask that you commit to at least three (3) follow up sessions as we cannot realistically evaluate the effectiveness or otherwise of your customised diet and exercise plan and/or modify accordingly.
It is expected that the session will begin at the agreed time. Any session that begins after this time due to late Client arrival for whatever reason cannot be extended beyond the agreed finish time.
If you do not arrive or call within 15 minutes of the agreed appointment, this will be considered a cancellation and our Practitioners will not be available for the remainder of the session.
7. Content of health assessments
Health assessments will include analysis of your medical history, blood work, diagnostic imaging and a physical evaluation where physical contact is necessary for body, weight and range of movement measurements to accurately establish your baseline bio-medical data and to continually review and compare that data as you progress. Photographs and video recordings of you will be taken for analysis and health record purposes.
8. Consultation fees
a. Initial Sessions are sold as a package of 3 consultation sessions at a total cost of $800 AUD. (The three sessions will cover discovering you and your goals, biomedical assessment, introduction to diet plan and implementation of all gathered data to start you on the new track). If needed pay as you go, each consultation cost is $290 AUD.
b. Follow up Sessions: Follow up Sessions: For each session following the Initial Sessions, the cost is $190 per session per 30 minutes sessions. For video conferencing sessions each 55 minute session is charged to $280 AUD, which has to be paid prior to having access to the virtual room.
c. Gym set up: A minimum of one hour will be charged at $120 AUD, and subsequent hours needed for each set up will be charged at the same rate. A travel time surcharge of $40 AUD will apply if further than 10km radius of the CBD.
d. Method of Payment: By card or Afterpay prior to commencement of each session including online consultations, all this through electronic payments at the premises or Cash.
e. Fees are reviewed annually, and any changes take effect on 1st January and apply to new or renewed contracts.
Reducing missed appointments is the most effective method for us to maintain a good relationship and achieve your goals. To help avoid missed appointments we provide a free text reminder service.
A minimum of 24 hours’ notice is required for cancellations otherwise the fully session fee will be charged, except in the event of extenuating circumstances beyond your control (e.g. accidents, emergencies or illness).
10. Definitions and interpretations
The meaning of terms used in this agreement are set out below.
Agreement means this document.
Client (‘you’) means the person or people receiving the Services.
Consultation Period means the number of consultation sessions agreed.
Initial Sessions means a package of 3 sessions at the beginning of a Consultation period.
Fee means price payable for the Service.
Follow-up Sessions means the sessions subsequent to the Initial Sessions.
Practitioner means a Transformative Health Coaching health employee providing the health assessment, coaching, counselling and/or psychotherapy services to the Client.
PACFA means the Psychotherapy and Counselling Federation of Australia.
Service(s) means the consultation process of health assessments, biomechanic assessments and counselling/coaching as set out in this Agreement.
Transformative Health Coaching (‘me/I/we’) means the organisation providing the Services set out in this Agreement.
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Fill out the blank spaces.
Give as much information as possible.
Do not sign the form as this is done in consultation with me unless online video conferencing sessions apply