- Please do your best toward success in the program: Coaching is an important investment in yourself, and toward improving your quality of life. You are encouraged to read all information handouts, ask questions at any time and about any protocol or methodology, practice the new and helpful strategies, cultivate a yearning to improve and make positive changes, be open-minded, and do the assignments outside of therapy with an interest toward improving yourself. Please understand that there are no guarantees as to the results of your coaching program, and that, while many individuals benefit from coaching to achieve goals, many are also unsuccessful for various reasons. Dr. Allen promises to give you his 100%.
- Please be on time & 24-hours notice required for any cancellations: Coaching sessions are 50 minutes. Testing and evaluation sessions may be 2 hours or longer depending on the extent of the assessment. The 50-minute time slot scheduled will be your time slot. Allen will work to help you find a comfortable weekly time slot, and please keep rescheduling to a minimum! Please contact Dr. Allen at least 24 hours before an appointment to cancel or reschedule. You will be expected to pay full fee for any canceled or missed sessions, unless given at least 24-hours notification to Dr. Allen.
- Contact outside of therapy: Dr. Allen can be reached at his office (847) 205-9605 or leave a message if you have any questions or need support. Your phone call will be returned soon, but within 24 hours. In emergencies only, I Dr. Allen can be paged at (847) 479-0200. Please let Dr. Allen know phone numbers where you can be reached, and how to leave confidential voice messages for you. If you prefer to email, please note that emailing is not always private due to the lack of protection on the Internet. Dr. Allen will do everything possible to protect client information on the Internet, but cannot be held responsible for privacy using this form of
- Full payment for services rendered will be required at the end of each session: Dr. Allen’s fees are within the usual and customary range for this community. Full fee of $ / each session is to be paid at the time of service. Sessions are 50 minutes, although time can be extended at a pro-rated hourly fee. Your hourly fee also covers cost of handouts and materials, cassette tapes, administration of your file, preparation of resources, and brief phone time in between sessions. Other fees charged include testing and test materials, report writing, lengthy phone sessions, ongoing coaching in between sessions, and attendance at meetings or collaboration with other professionals you have authorized. Receipts for services are also available. For payment of services, Dr. Allen accepts checks, Visa or Mastercard, or cash. Allen reserves the right to terminate the doctor-client relationship for non-payment of services. If financial difficulties arise, an alternative payment schedule may be provided at Dr. Allen’s discretion. Brief and intensive coaching options are also available and may be effective if financial constraints arise.
- Termination policies: If at any point in time you desire to initiate termination of coaching, please contact Dr. Allen for a final session or phone conversation to discuss the reasons, explore alternatives, and for closure. Referrals for outside resources are available if
- Confidentiality: The information you tell Dr. Allen will be treated with great care. Dr. Allen respects your full rights to privacy and confidentiality. He will provide you with a (HIPAA) – Health Insurance Portability and Accountability Act contract, which indicates your rights to privacy, and the limitations of confidentiality. Please feel free to ask any questions or address any concerns you may have.
I the client (or his or her parent or guardian) have read the above information of this coaching contract and I understand and agree to its contents. I have gone over this contract with Dr. Allen, and I understand these policies, rules, questions, issues regarding confidentiality, payment issues, and my rights as a client. I have had all of my initial questions answered fully, and I understand that I may ask questions at any time concerning all aspects of my program. I do hereby seek and consent to take part in coaching with Dr. Allen, and I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any strategies provided by Dr. Allen. I am aware that I may stop my program at any time, though I will be responsible for paying for services I have already received, anmd have a final conversation with Dr. Allen for closure.
|Signature of Client (or parent/guardian)||Printed Name||Date|
|Minor’s Signature (if client is over 12 years old)||Printed Name||Date|
|Signature of Dr. Ben Allen||Date|