Healthcare Coaching Form

HEALTHCARE COACHING FORM

Patient Information

Date of birth:    Gender:

Phone Email Text Mail

Emergency Contact

Insurance Information

Medical History

Lifestyle, Goals & Coaching Plan

Readiness to change: Not ready Somewhat ready Ready

In-person Phone Video Email

Consent for Healthcare Coaching

I, the undersigned, authorize participation in health and wellness coaching provided by the designated coach. I understand that coaching is a client-directed, collaborative process to support health behavior change and is not psychotherapy, medical diagnosis, or medical treatment. The coach will use evidence-informed coaching techniques; the coach will not prescribe medications or provide medical diagnosis.

I understand the potential benefits include improved self-management, increased health-related knowledge, and support for behavior change. I also understand potential risks include emotional discomfort when addressing health issues, and that progress is not guaranteed. I will notify my medical provider of coaching activities and will continue to seek medical care as recommended by licensed medical professionals.

I may withdraw consent at any time by providing written notice to the coach. Withdrawal will not affect obligations incurred prior to receipt of notice. I consent to participate voluntarily and understand that I am responsible for decisions and actions taken as a result of coaching.

Limits to confidentiality: information disclosed is confidential except as required by law, including but not limited to reasonable suspicion of child, elder, or dependent adult abuse; imminent risk of harm to self or others; or when disclosure is required by a court order. In such cases, information will be disclosed only to the extent necessary.

Please indicate your informed consent and acknowledgment of the foregoing statements:

I acknowledge that I have read and understand the nature and limits of healthcare coaching.

I acknowledge the risks and agree to participate voluntarily.

Authorization to Share Information

I authorize the coach to share pertinent coaching notes and summaries with the following healthcare providers and/or designated persons for continuity of care (specify names and relationships):

This authorization expires on:

I understand that I may revoke this authorization at any time in writing, except to the extent that the coach has already acted in reliance upon it.

HIPAA / Privacy Acknowledgment

I acknowledge that I have received or been offered a notice describing how protected health information about me may be used and disclosed and how I can access this information. I understand the coach's responsibilities to protect my privacy and the situations in which information may be disclosed without my authorization as described above.

I acknowledge receipt of the privacy information and my rights regarding my protected health information.

Fees, Payment & Cancellation Policy

Fees for coaching services, cancellation requirements, and payment arrangements shall be agreed upon prior to commencing services. Unless otherwise agreed in writing, cancellation less than 24 hours prior to a scheduled session may result in full session charges. Clients are responsible for timely payment of fees and any costs incurred for missed appointments.

I understand and accept the fee and cancellation policy described above.

Additional Information

Acknowledgments and Certifications

By signing below, I certify that the information I have provided on this form is accurate and complete to the best of my knowledge. I understand the scope of coaching services and the limits of confidentiality described herein. I authorize the coach to communicate with my listed healthcare providers as necessary for my coaching plan.

If signing on behalf of the patient (parent, guardian, or authorized representative), indicate your legal relationship below and provide documentation of authority upon request.

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