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Informed Consent

Nephrite LLC

Colleen Dunahee Chronic Pain Coach

Thank you for choosing Nephrite Chronic Pain Coaching, I look forward to working with you. This informed consent and waiver document, Please read it carefully and let me know if you have any questions.

Disclosure:

Colleen Dunahee of Nephrite LLC is a Chronic Pain Coach, not a licensed physician. It is the responsibility of the client to clear any medical concerns with their provider. I am not a psychologist, psychiatrist or licensed mental health professional. It is possible that in the course of our sessions issues may arise that will need the skill of a licensed mental health professional and it is the responsibility of the client to seek out those services.

Coaching does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association. Coaching is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment. Understand that coaching is not to be used as a substitute for professional advice by legal, medical, financial, business, spiritual or other qualified professionals. Agree to seek independent professional guidance for legal, medical, financial, business, spiritual or other matters. Any decision or actions regarding them are solely your responsibility.

Qualifications:

I am a licensed Physical Therapist in the state of Wi. I have chosen to proceed with this business as a coach rather than a PT due to licensure restraints. I have completed multiple courses on evidence based pain research and education including effective diagnosis and treatment of neuroplastic pain, Pain Reprocessing Therapy, as well as Brainspotting and these are the skills that I will bring to our sessions. It is a mind-body approach to pain that is grounded in research.  

Consent

Sessions are voluntary and the you can discontinue at any time.  You can expect conversations to be confidential unless you share information that you intend to harm yourself or someone else. Certain topics may be anonymously and hypothetically shared with other coaching professionals for training OR consultation purposes only. Most sessions will be done over Zoom, which is HIPAA compliant as stated on their website. As a coach I do not keep medical records.

Nephrite policy

Payment is due at the time of service. Payments can be made with cash, checks made out to Nephrite, or Venmo. Sessions are $150  for 90 minutes and $120 for 60 minute sessions. The initial session is 90 min and after that the client can decide if they want 60 or 90 min sessions. Nephrite requires 12 hour notice via text or phone for cancellations. Any cancellation with less that 12 hours notice must pay 50% of session fee.

I Agree
 Check box to indicate that you have read and are in agreement with the information stated above and releases Nephrite LLC and Colleen Dunahee from liability


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Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
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Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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