Coach Leszek Koprowicz

Coaching & Consulting

(224) 707-2308

Informed Consent Agreement

I agree to receive coaching services from Coach Leszek Koprowicz

COACHING IS NOT PROFESSIONAL COUNSELING, THERAPY, OR ANY LICENSED SERVICE:

My coaching services are neither therapy, professional counseling, nor any licensed service. This means that my work together does not create a provider-patient relationship between us, Coaching services may not be appropriate for everyone. If you have concerns about a medical or mental health condition, please schedule an appointment with a medical provider. Coaching services are not a substitute for medical advice or licensed mental health services. Coaching services include wellness and education services to assist in navigating challenges and building resiliency. Coaching services do not include "the therapeutic process of: (i) conducting assessments and diagnosing for the purpose of establishing treatment goals and objectives and (ii) planning, implementing, and evaluating treatment plans using treatment interventions to facilitate human development and to identify and remediate mental, emotional, or behavioral disorders and associated distresses that interfere with mental health.," as defined by Illinois law. Coaching services also are not " the rendering to individuals, groups, families, organizations, or the general public a service involving the application of clinical counseling principles, methods, or procedures for the purpose of achieving social, personal, career, and emotional development and with the goal of promoting and enhancing healthy self-actualizing and satisfying lifestyles whether the services are rendered in an educational, business, health, private practice, or human services settings" by Illinois law. My coaching services are mainly based on brainspotting: a method where traumatic or emotional content is accessed and processed through specific eye positions, linking visual focus to emotional states. Brainspotting uses the brain's natural ability to heal by finding and focusing on eye positions that correlate with the emotional or traumatic memory.

RISKS, BENEFITS, AND ALTERNATIVES TO TREATMENT: Coaching involves both benefits and risks. Risks include the possibility of experiencing uncomfortable levels of feelings like sadness, guilt, anxiety, anger, loneliness, and helplessness. Coaching often requires recalling experiences, some of which may be unpleasant. Coaching may involve making changes that can feel uncomfortable to you and those close to you. Should you notice any negative effects, please tell us immediately. You may stop coaching at any time. I will make every effort to remedy the situation or provide you with names of other coaches should you prefer a referral. Coaching has been shown to have benefits for those who undertake it. It often leads to a reduction of feelings of distress, and to better relationships and resolution of specific problems. The objective is to find more peace, joy, and healthier relationships.

REMOTE COACHING SERVICES: The coaching services may be remote. Remote technology platforms incorporate network and software security protocols to protect your confidentiality. Consistent with privacy laws, my technology includes safeguards intended to secure and ensure the integrity of client information.

I utilize technology that: (i) complies with the relevant safety laws, rules, regulations, and codes for technology and technical safety for devices that interact with clients; and (i) offers sufficient quality, size, resolution, and clarity such that I believe I can safely and effectively provide remote coaching services.

Although you are not receiving licensed mental health services from me, I work to comply with applicable state and federal laws, which may still require us to protect the confidentiality and privacy of certain medical and personal information. I have implemented policies to ensure my compliance with these requirements. I strive to explain the benefits, risks, and alternatives to you receiving coaching services remotely. Technology platforms can facilitate high-quality coaching in a convenient and effective manner. The risks may include, but are not limited to, the following: (i) information transmitted may not be sufficient (for example, poor resolution of images); (i) technical deficiencies or failures; and (i) your information could be accessed or intercepted by an unauthorized person. You can choose not to receive or halt remote coaching services.

INDEMNIFICATION AND ASSUMPTION OF RISK: As a condition for receiving coaching services, you agree to indemnify us against all claims, liabilities, losses, damages, suits, costs, and expenses (including reasonable attorney's fees) to the greatest extent permitted by law and as they relate to your failure to follow my instructions, communicate to us about any problems you encounter during my services, or update me about changes to your health, and you agree to assume all risk of property damage, injury, or death associated with such failures.

Although I aim to provide useful and correct guidance, I make no warranty as to the effectiveness of my coaching services for you. Accordingly, I disclaim all liability to any party for any direct, indirect, implied, punitive, special, incidental, or other consequential damages arising directly or indirectly from my coaching services. Coaching services are provided as-is, without additional warranty.

CONFIDENTIALITY: Although you are not receiving licensed mental health services from me, I work to comply with applicable state and federal laws, which may still require us to protect the confidentiality and privacy of certain medical and personal information. As part of the coaching process, I am bound by ethical responsibilities to keep confidential the information shared during the sessions, and I will not release any information without your written permission. There are important exceptions to the confidentiality of our relationship. I am required by law to reveal certain information under the following circumstances:

a) Disclosure of serious intent to do harm to self or others

b) Disclosure of child abuse or my suspicion of child abuse, elder abuse, or dependent adult abuse

c) If a court of law orders the release of specific information

APPOINTMENTS: The length of a usual appointment is sixty (60) minutes. Appointments are usually scheduled weekly or bi-weekly and on a regular basis until you have accomplished most of your goals or other arrangements are made.

CANCELLING AND MISSED APPOINTMENTS: Cancellation of appointments must be made at least 24 (twenty-four) hours in advance. For Monday appointments, you must cancel by 12:00 p.m. on the previous Thursday so I can offer that time to another client. Late cancellations will be charged at 1⁄2 the regular hourly fee. One courtesy waiver per year will be allowed. If you have a true emergency, you will not be charged. If you do not show up for your appointment, I will charge you for the full cost of the appointment.

PAYMENT: Payment is expected at each session unless other arrangements have been made in advance. You are responsible for payment for all services rendered either by cash, Venmo, Cash app, or check. All checks will be paid to CHIRON LTD.

CHECKS/OVERDUE ACCOUNTS: There is a twenty-five-dollar ($25) service charge for all checks returned by the bank.

THERAPEUTIC TOUCH: On occasion, and only with your permission, I will use therapeutic touch during trauma coaching sessions. The touch may involve you remaining on your chair or couch and receiving a supportive hand to hold, or the grounding touch of a hand on your shoulder, neck, or back. You may request not to be touched or remove consent for therapeutic touch at any time.

TELEPHONE, TEXT, AND EMAIL POLICY: Generally, I ask that clients reserve discussions for problems that arise between session sessions for the next scheduled appointment time. I encourage you to use the resources you have and to reach out to your support system. Unless there is an emergency, my schedules do not permit me to talk on the phone, respond to lengthy texts, or answer lengthy emails in between sessions. If you feel the need to text or email information beyond the routine scheduling of appointments, I will wait to discuss the content in my next scheduled session. If telephone calls are necessary for a client emergency, please schedule a time for a telephone consultation, which will be charged at my regular rate (in 15-minute increments). Please do not text anything other than appointment times, as confidentiality is not secure with texting.

INSURANCE: I do not take any insurance yet.

PHYSICAL EXAMINATION: I strongly recommend that each client obtain a thorough physical examination prior to commencing training. This is especially important if you are suffering symptoms of anxiety or depression, headaches, and/or weight gain/loss. Symptoms may be biologically caused or may be there for a protective reason.

TRAINING AND SUPERVISION: Your case may be discussed in a group or individual supervision format with a licensed supervisor present for feedback, education, and discussion.

EMERGENCIES:

Coaching services are available only during scheduled office hours. In a crisis, you may utilize:

Community Counseling Centers of Chicago (phone: 773-365-7277) or call 1-800-273-TALK (8255) to reach a 24-hour crisis center, or text MHA to 741741 at the Crisis Text Line. In the case of suicidal ideation, call 988 to reach the suicide hotline. If you experience a medical emergency (including suicidal or homicidal thoughts), immediately call 911. You may also contact the National Suicide Prevention Lifeline, which offers a free 24-hour hotline at 98.

I understand and agree that a photocopy or electronically reproduced/signed copy of the original of this informed consent shall have the same effect as an original.

If you have any questions about my policies or about coaching, please ask before signing below. Your signature indicates that that you have read my policies and agree to enter coaching under these conditions. Further, it indicates your understanding that I may terminate coaching fi you do not comply with the policies or if I feel you are not benefiting from treatment.

Client Name: _______________________________________ E-mail:______________________________

Client Signature: ________________________________________ Date:___________________________________