Coaching Client Registration Form 

Please enable JavaScript in your browser to complete this form.
Address
Emergency Contact Name
Have you recently experienced any of the following crisis events?
(Select all that apply)
How did you hear about us?

Crisis Care Terms and Conditions

  • As a client, I understand and agree that I am fully responsible for my well-being during my crisis care sessions, including any choices and decisions that I make.
  • I understand that crisis care conversations are part of a partnership I have with my crisis care provider that is designed to holistically assist in processing experiences and events, assess current signs and symptoms I may be experiencing, and to facilitate the creation and implementation of a personal recovery plan.
  • I understand that personal crisis care is a comprehensive process that may cover topics from all areas of my life, including but not limited to: work, finances, health, relationships, education, personal development, spirituality, and recreation. I acknowledge that deciding how to deal with these topics and implement my choices is exclusively my responsibility.
  • I understand that I am always free to reject any ideas, insights, perceptions, or requests made by my crisis care provider at any time.
  • I understand that crisis care conversations are not to be used in lieu of professional advice. I will seek professional or clinical guidance for legal, medical, psychological, financial, business, religious, or other matters.
  • I understand that crisis care conversations do not treat mental disorders as defined by the American Psychiatric Association. I understand that crisis or critical event processing is not a substitute for counseling, psychotherapy, psychoanalysis, clinical mental health care, or substance abuse treatment, and I will not use it in place of any form of such therapy. I further understand that if topics arise that I or my crisis care provider believe would best be served by seeing a mental health professional, an appropriate referral will be made. If I am under the care of a mental health professional, I will consult with him/her regarding the advisability of working with a crisis care provider and will let them know of my decision to proceed.
  • I am aware that I can choose to discontinue crisis care provision at any time.
  • I will contact my crisis care provider at least 24 hours in advance to reschedule a session. Any cancelation of a session with less than 24-hour notice will result in forfeiting the session.
  • I understand that my crisis care provider will maintain the confidentiality of our relationship within the requirements of the law unless I have given written permission to use my name in testimonials or other public domains. I also understand that to protect myself and others, exceptions to confidentiality will include risk of harm to myself or others, or admission of involvement in a major crime.
  • I understand that the crisis care provider engages in training and continuing education to pursue and/or maintain crisis care support credentials.

The crisis care provision process requires the names and contact information of all clients for the confidential records of The Resilience Resource. By signing this agreement, you agree to have your name, e-mail address and start & end dates of crisis care support shared with The Resilience Resource team for the sole purpose of verifying the provider/client relationship. No other information, including notes, will be shared. You are also agreeing to have certain topics anonymously and hypothetically shared with other crisis care professionals for training or consultation purposes.