Informed Consent

By requesting a tele consultation, you are requesting to enter into a coach / patient relationship with either a therapist or coach who is independently contracted with U ARE HEARD LLC, to participate as a Network Coach.  The consulting Network Coach shall be the actual provider of the professional counseling services to you. While UAREHEARD provides certain technology and administrative services to you and the Network Coach, UAREHEARD does not itself provide the professional coaching services to you.  Therefore, you agree to pay U ARE HEARD on behalf of the Network Coach for the tele coaching at the time they are requested. Fees for sessions are 175.00 for each visit.  They are due the day of a scheduled session.

You agree to the entry of your medical records into the U ARE HEARD computer database that is maintained by U ARE HEARD for the Network Coach and understand that reasonable measures have been taken to safeguard your medical information, in accordance with federal HIPAA standards. U ARE HEARD recognizes your privacy and, in accordance with our Privacy Policy, will not release information to anyone without your written authorization or as required by law, or in accordance with your health insurer’s privacy policy if applicable.

There is no guarantee that you will be treated as a patient by a Network Coach if, for example, a Network Coach determines that your difficulties / condition cannot be properly treated by him/her.

If you are treated by a Network Coach, you have a right to your medical records in accordance with applicable law.

Expected Benefits:

• Improved access to care by enabling a student to remain in his/her local site (e.g., home, college dorm room) while the coach consults from a distant site.
• More efficient coaching evaluation and management.

Possible Risks with tele coaching are:

• The video connection may not work or it may stop during the meeting
• The video may not be clear

You acknowledge that you understand and agree with the following:

I understand that the laws that protect privacy and the confidentiality of medical and mental health information also apply to telecoaching and that no information obtained through the use of these meetings, which identifies me, will be disclosed to researchers or other entities without my written consent.

1. I understand that I have the right to withhold or withdraw my consent to the use of tele coaching in the course of my care at any time, without affecting my right to future care or treatment.
2. I understand the alternatives to tele coaching consultation as they have been explained to me.
3. I understand that tele coaching may involve electronic communication of my personal medical or mental health information to medical practitioners who may be located in other areas, including out of state only with your consent.
4. I understand that I may expect the anticipated benefits from the use of tele coaching in my care, but that no results can be guaranteed or assured.
5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.. The above mentioned person will also maintain confidentiality of the information obtained.

Patient Consent To The Use of Tele coaching

I have read this Informed Consent form carefully (or have had it read carefully to me), and I understand the information provided in it.  I understand the risks and benefits of tele coaching and that I will have the opportunity to ask any questions I may have regarding it with the consulting coach at the onset of and during my consultation, and I can end the consultation at any time should any of my questions not be answered to my satisfaction.

I hereby give my informed consent to participate in a tele coaching visit under the terms described in this consent form.

By clicking ‘Sign Up’, I hereby state that I have read this Informed Consent form carefully (or have had it read carefully to me), I agree to its terms, and wish to proceed with my consultation.

(Rev.7.19.19)