Healthcare Coaching Consent Form

Healthcare Coaching Consent Form

Participant Information

Insurance Information (If Applicable)

Medical History

Please provide accurate and complete medical information. This information helps the coach plan safe and appropriate coaching. If you are receiving medical treatment, coordination with your treating provider may be recommended.

Coaching Services: Nature and Purpose

Healthcare coaching is a collaborative, non-clinical process that supports behavior change, health goal setting, self-management, and lifestyle modification. Coaching is not psychotherapy, counseling, medical diagnosis, or treatment. The coach may provide education, goal-setting, motivational support, and coordination with other healthcare providers when authorized.

Risks, Benefits, and Acknowledgement

I understand that participation in coaching may involve discussion of sensitive health information and that possible benefits include improved self-management, increased adherence to healthy behaviors, and improved quality of life. Potential risks include emotional discomfort, the need to modify activities due to illness, and unintended consequences from lifestyle changes. I acknowledge that no specific outcome is guaranteed.

I acknowledge that I have read and understand the risks and potential benefits described above.

Confidentiality and Its Limits

Information disclosed during coaching sessions is considered confidential and will be maintained in a secure record. However, confidentiality is limited in the following circumstances: (1) if there is an imminent risk of harm to self or others; (2) suspected abuse or neglect of a child, elder, or dependent adult; (3) legal compulsion such as a court order or subpoena; and (4) when disclosure is necessary to coordinate care with other providers and the participant has authorized such disclosure.

I understand the limits of confidentiality and the circumstances under which information may be disclosed without my prior consent.

HIPAA / Privacy Acknowledgment and Authorization

I acknowledge that I have been informed about the privacy practices that govern the use and disclosure of my protected health information (PHI) for the purposes of providing coaching services. By signing this form I authorize the coach and affiliated practice to use and disclose PHI as necessary to provide coaching, arrange referrals, communicate with my healthcare providers, and process billing as applicable.

Authorization expires on:

I authorize use and disclosure of my PHI as described above and understand I may revoke this authorization in writing except to the extent that action has already been taken in reliance on it.

Release of Information to Family or Third Parties

If you wish to permit the coach to share information with specific individuals (family members, caregivers, or other providers), list them below and describe the scope of information that may be shared.

Telehealth, Phone and Recording Consent

Coaching sessions may be offered in person, by telephone, or via secure video conferencing. Electronic communications carry confidentiality risks. Recording of sessions is not permitted without separate written consent.

I consent to receive coaching via telephone or video conferencing and understand the potential privacy risks.

Right to Withdraw and Voluntary Consent

Participation in coaching is voluntary. I understand that I may withdraw my consent and discontinue coaching at any time. I understand that if I withdraw authorization for use or disclosure of PHI, services may be impacted if coordination with other providers or billing is required.

I acknowledge my right to withdraw consent at any time by submitting written notice.

Fees, Scheduling and Cancellation

Fees, insurance coverage, and cancellation policies will be discussed prior to services. I agree to the cancellation and fee policies explained to me and accept responsibility for timely payment of any fees not covered by insurance or otherwise agreed.

I acknowledge that I have been informed of applicable fees and cancellation policies.

Additional Information or Concerns

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