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VIVID Relationships Coaching Agreement

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Please briefly share why you are seeking help today? *

Who else will be in sessions with you?

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How did you hear about Dr. Viviana/VIVID Relationships? *

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Relationship Status: *

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Scope of Services: Please type your FULL NAME to indicate you have read and understand this statement: 1. This is a Coaching program and Dr. Viviana will not provide you with psychotherapy services. If you are looking for psychotherapy services and you are in TX/C/NY/FL, please visit HOUSTONRELATIONSHIPTHERAPY.COM for details and availability. 2. The Coaching Program is intended for COUPLES who are in need of direct advising for relationship issues. 3. Coaching is not currently a regulated industry, so the overall efficacy and success of your experience will largely depend upon your willingness to complete the in-session and homework exercises. 4. You can expect your provider to be honest and direct, asking straightforward questions and offering feedback to help you keep moving forward. 5. Relationship coaching does not address or diagnose mental disorders as defined by the American Psychiatric Association. These sessions are not a substitute for counseling, psychotherapy, mental health care, or substance abuse treatment. *

Regarding the Discussion of Sex-Related topics: Please type your FULL NAME to indicate you have read and understand this statement: Due to the nature of intimate relationships, sexual issues are often discussed at VIVID Relationships. Please note that we are qualified to provide sexual education in several formats including, but not limited to, books, videos, models, samples, verbal explanation, paper handouts, etc.. We will NEVER encourage or tolerate any nudity or touching during our sessions. Please contact our office should you have any questions or concerns regarding what relationship and sex coaching is or is not. *

About Confidentiality: Please type your Full Name to indicate you have read and understand this statement: The session content and all relevant materials will be held confidential. Due to licensing state laws governing psychotherapists in TX, CA, NY, and FL, Dr. Viviana must abide by the limitations to confidentiality as itemized here: 1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm. 2. If a client threatens grave bodily harm or death to another person. 3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years. 4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses. 5. Suspected neglect of the parties named in items #3 and #4. 6. If a court of law issues a legitimate subpoena for information stated on the subpoena. 7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney. 8. If the client discloses that he/she or any other named victim has been the victim of emotional, physical or sexual misconduct by a current/previous psychotherapist, the therapist will report any incidences to the appropriate Board. Administrative staff may have access to your confidential data. Every staff member is held to the same strict confidentiality practices. *

Kids in Session: Please type your FULL NAME to indicate you have read and understand this statement: Infants are allowed in session but please be aware that they may be a distraction to either you or your coaching. Children of any age are NOT allowed to be within earshot of the meeting space. Please be advised that your coach will ask you to reschedule your session (your session fee will not be refunded) should you bring children to your session. *

If You Come to a Session Impaired: Please type your FULL NAME to indicate you have read and understand this statement: We will not consult with individuals who appear to be impaired by drugs or alcohol of any sort. Please note that if you come to a session and appear to be under the influence of any drugs/medications (legal or illegal) or alcohol, we will ask you to reschedule (your session fee will not be refunded) and refuse to see you at that time. *

Fees and Payment/Cancellation Policy: Please type your FULL NAME to indicate you have read and understand this statement: Payment (first installation or in full) is due at the time of scheduling. Coaching Package of 8 hours is currently 3800 with Dr. Viviana and 1000 with a VIVID Relationships Provider. Because we operate "By Appointment Only," cancellations with less than 24 hours’ notice will result in a fee equal to the total amount of the missed session debited from your credit card. After two no-shows/late cancellations, client will pre-pay before services are rendered. Clients who have pre-paid agree to have the entire session fee deducted from their pre-payment in cases of no-shows and late cancellations. PLEASE NOTE: By scheduling a session with VIVID Relationships, you have agreed to have your credit card on file to be used under the circumstances outlined here. You may discontinue coaching sessions at any time. If you have purchased a pre-paid package and choose to discontinue, you may receive a 50% refund of the discounted amount you paid for any unused pre-paid sessions. All pre-paid sessions must be used within 6 calendar months of purchase. (No exceptions please.) Any credit card disputes will result in VIVID Relationships producing a copy of this signed agreement to the company notifying us of the "chargeback" in order to recover our fees. Any additional "chargeback" fees will also be assessed to you the client. Failure to pay for our services or fees incurred by fraudulent credit card disputes will result in immediate termination of services and referral to other agencies. *

Person responsible for payment: If self, please type your name. If someone else, please type their name, phone number, and email. Please note that they will have to agree to our payment policy in order to charge them for your sessions. If they do not have that on file, you will be responsible for any payments due. *

Payment Policy: Please type your FULL NAME to show that you understand that you are ultimately financially responsible for any balance. VIVID Relationships does not bill to any third party payers nor will we provide any information other than receipts of payment made by you to you should you decide to seek reimbursement for our services. We will obtain payment at the time of service or in the case of a late cancellation or no-show. *

How did you hear about Dr. Viviana/VIVID Relationships? Please be specific: *

Emergency Contact and Phone Number: We will only contact this individual with your consent or without your consent should there be a threat to your physical safety. We may also choose to call upon 911 Emergency Services and all costs incurred will be your responsibility. *

Crisis or Emergencies: Please type your FULL NAME to indicate you have read and understand this statement: If the client is in a state of crisis or emergency, Houston Relationship Therapy recommends contacting local emergency services (ex. "911"), a crisis line, or an agency local to the client. Clients may utilize the following crisis hotlines in the United States: 1-800-SUICIDE or 1-800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY). *

Acknowledgment and Release of Liability: Please type your FULL NAME to indicate you have read and understand this statement: By signing this disclosure and consent statement, I acknowledge that I understand the above information. I agree to hold harmless VIVID Relationships and my consultant from all liabilities and claims which may arise as a result of my participation in coaching. *

First Partner's Signature *

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I HAVE READ THIS AGREEMENT IN ITS ENTIRETY AND AGREE TO ENTER IN TO CONSULTING AT VIVID RELATIONSHIPS.

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