Consent

GET IN TOUCH

Contact Details

If you would like someone from our staff to contact you regarding an inquiry for yourself, a child or a friend – please fill out the following information and we’ll be in touch within 24 hours.

If you are experiencing an immediate medical or mental health emergency, please dial 911.

You Have a Voice

Be Heard Now

This contract indicates consent for distance-oriented coaching, which take place over a HIPAA compliant telehealth platform.

By signing this contract, I agree to the following:

  • To find a quiet and protected space for our virtual sessions.
  • Sessions should not be cancelled or changed with less than 48 hours notice unless illness is the reason given. Otherwise there is a late cancel or ‘no show’ fee charged.
  • That during our session time, no one else will be present in the room (unless indicated to the coach and discussed prior to session).
  • That no phone calls, texts, emails or web surfing will occur.
  • That if there is a loss of connection, the coach will initiate the call back.
  • Sessions are scheduled for 60 minutes to account for any connection disruption, but the session shall last 40-45 minutes.
  • The session and the chat will not be recorded nor will screen shots be taken unless expressly discussed prior to session and with clinical goals in mind.
  • All rules regarding mandated reporting and reporting harm to self or others remain the same as in office sessions as per LMFT / LPC / LCSW / PsyD / Coaches ethical standards and legal protocol.
  • In case of a crisis an address and contact information on campus needs to be given to the coach before sessions begin.

By signing this contract, I indicate my compliance with the above stated expectations. I reserve the right to revoke my consent, in writing, at any time. This consent will be valid for 1 year following the date of signature

Address

152 Simsbury Rd
Avon CT 06001

Phone

860-214-7583

Email

info@uareheard.com