The Identity Process™ Informed Consent

 Welcome to the Identity Process™

I am a certified Identity Process™ coach and I look forward to supporting you in this journey of self-discovery. The Identity Process™ was created by Dr. Jodi Tompkins, a licensed Clinical Psychologist specializing in identity development. It evolved out of her years of clinical practice and doctoral research in the area of identity development for emerging adults and has expanded to include people of all ages and in various stages of life transitions. The program will provide you with guided reflections and practical tools that will help you discover a deeper awareness of who you are and a better understanding of the way you think, feel, react, and relate with others.

I want to prepare you with what to expect and encourage you to ask me any questions when we meet together. Please read the information carefully and your signature at the end of this document will indicate that you have understood and agree to the following:

The Identity Process™ is not Psychotherapy

The Identity Process™ is not psychotherapy or counseling. The Identity Process™ is a 10-week program in which we will collaborate together to support your wellness and growth. It focuses on identifying your strengths, understanding unhelpful patterns from your past, and cultivating your potential to thrive in your future. We will work through information about identity that will help you come to a better understanding and acceptance of yourself. Your outcome will depend largely on your willingness to be authentic, self-reflective, and engaged in this process.

Prior to beginning The Identity Process™, you will meet with me for a brief initial phone consultation to determine if coaching is a good fit for you. I will explain the Identity Process™ and answer any questions you may have. If at any time during the coaching process it is determined that there are more serious mental health concerns or safety issues, you will be referred to meet with a licensed therapist to provide the help and support that you need.

Fees & Cancellations

A standard Identity Process™ coaching session is for 50 minutes and the fee is $___. If cost is a concern for you, this can be discussed prior to our first session. Once a session has been scheduled, 24-hour advance notice is requested for cancellations otherwise session may be billed at 50%. Of course, exceptions will be made for unforeseen circumstances.

Payments are required at the end of each session and arrangements will be agreed upon prior to starting our work together.

Telehealth Sessions

Because you may choose to use telehealth in its various forms, I want to provide you with some information about this avenue. Telehealth includes video conferencing, phone sessions, and other forms of electronic interactions such as setting up appointments or transmitting data via email. Telehealth has the same confidentiality level as face-to-face counseling. Exceptions to confidentiality in telehealth are identical to those in face-to-face therapy, as outlined in this agreement.

Telehealth has some inherent risks that I want to point out. Despite reasonable efforts, the transmission of personal information could be disrupted or distorted by technical failures. The transmission of personal information could be interrupted by unauthorized persons. I am constantly working to maintain the security of your personal information by using secure methods of communication, but I want you to know that breaches can occur and failures of equipment during our sessions could be a problem. If your session is interrupted by some kind of technical problem, it will be re-scheduled for the remaining time.

Confidentiality

Confidentiality is an important and necessary part of the coaching process. As a general rule, the information you share with your coach will be kept confidential, unless you have given your consent to disclose it. There are, however, some exceptions to this rule that are important for you to understand before you share personal information in a coaching session.

Exceptions to Confidentiality

In some situations, confidentiality will be broken whether or not you have given your permission. These situations are listed below. Confidentiality cannot be maintained when:

1) You state that you plan to cause serious harm or death to yourself, and I believe you have the intent and ability to carry out this threat in the very near future. Steps will be taken to make sure that you are protected from harming yourself.

2) You state that you plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future. In this situation, I must inform the person who you intend to harm as well as the local police.

3) You identify a minor who is being abused (physically, sexually or emotionally) or the abuse has occurred in the past by an identified perpetrator who still poses a threat to minors. In this situation, I will report the abuse to Child Welfare Services.

4) You state that you know of an elder or dependent adult who is being abused (physically, sexually or emotionally) or that has been abused in the past by an identified perpetrator who still poses a threat to elder or dependent adults. In this situation, I will report the abuse to Adult Protective Services.

5) I may consult with Dr. Tompkins as needed in order to provide you with the best care and support.

Other Information

If you are seen outside of our coaching sessions, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance. If you make the first acknowledgment, I will be more than happy to speak briefly with you, but I will not engage in any discussions of a confidential nature in public places.

Printed Name:_______________________________ Signature:_______________________________ Date:________________