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Please read this consent agreement carefully before beginning coaching services.

This document outlines the nature of coaching at Specthrive Wellness & Behavioral Health LLC and the boundaries of our work together. If anything is unclear, we will discuss it before signing.

You can submit this form electronically (by typing your signature) or print it and sign by hand. Both methods have the same legal effect.

Nature of Coaching Services

Coaching at Specthrive Wellness & Behavioral Health LLC is educational, strategic, and goal-oriented. Our work centers on practical support, skill-building, and helping you or your child move toward specific personal, parenting, or executive-functioning goals.

Coaching is forward-focused and collaborative. You set the goals; I bring tools, structure, and accountability. Common areas of focus include autism support (including late diagnosis), parent coaching, school and IEP guidance, and burnout or executive-functioning support.

Coaching Is Not Psychotherapy

Coaching is not psychotherapy and is not a substitute for mental health care.

I do not diagnose, treat, or manage mental health conditions during coaching sessions.

Coaching is not a medically necessary service and does not constitute medical or psychiatric care.

If you are seeking treatment for a mental health condition, you should engage in therapy with a qualified mental health professional.

Dual Role Disclosure

I am a Licensed Professional Clinical Counselor (LPCC) in addition to providing coaching services. My therapy and coaching roles are intentionally separate.

When we are working together in coaching, I am NOT acting as your or your child’s therapist. Coaching does not establish a therapeutic, clinical, or treatment relationship.

If you would like to engage in therapy, that would require a separate intake, separate consent, and separate documentation, and may include insurance verification.

Confidentiality and Its Limits

What we discuss in coaching sessions is treated with respect and held in confidence. I will not share information about our work without your written permission, except in the limited circumstances below.

I am required by law to break confidentiality if:

There is risk of serious harm to yourself or someone else.

A child, elder, or vulnerable adult is being abused or neglected.

A court orders the release of records.

Communication and Boundaries

Coaching may include brief communication between sessions, such as quick email check-ins, scheduling, or follow-up on a strategy. These exchanges are not 24/7 and are not a substitute for sessions.

Coaching is not for crisis support. I do not respond to messages outside of business hours and cannot guarantee timely replies for urgent matters.

Emergencies and Crisis Care

Coaching is not crisis care. If you or your child are experiencing a mental health emergency, do not wait to hear from me. Please use one of the resources below.

Call 911 or go to the nearest emergency room.

Call or text 988 to reach the Suicide and Crisis Lifeline.

Contact your county’s mobile crisis team or your established mental health provider.

Fees and Payment

Coaching is private-pay only. It is not billed to insurance and is not reimbursable as a medical service.

Specific session fees, package structure, and payment terms are described in your separate coaching agreement.

Scope and Limitations

Coaching does not include medical, psychiatric, diagnostic, or emergency services.

I cannot guarantee specific outcomes from coaching. Progress depends on your engagement, follow-through, and circumstances outside of our sessions.

Transition to Therapy if Clinical Needs Arise

If, during coaching, I identify needs that fall outside the scope of coaching (such as significant mental health symptoms, safety concerns, or a need for clinical assessment), I will discuss this with you.

Transitioning to therapy requires a separate intake, a separate signed consent, and a clear handoff. I may also refer you to another provider when that is the better fit.

Client Responsibility

Coaching is collaborative. Your active participation, openness, and willingness to apply strategies between sessions strongly influence what we are able to accomplish together.

You are responsible for the choices you make and the actions you take based on our coaching work.

Sign and Submit

Sign this form by typing your name, your email, your relationship to the client, today's date, and checking the agreement box below. Under the federal ESIGN Act and Minnesota's Uniform Electronic Transactions Act (UETA), your typed name has the same legal effect as a handwritten signature when provided with the intent to sign. To sign on paper instead, print this form and complete the same fields by hand.

Nancy Nyabuti, MA, LPCC
Outpatient Mental Health Therapist · nancy.nyabuti@specthrivewbh.com · 612-208-6549 · specthrivewbh.com

Review your answers

Please confirm everything looks right before sending.

Nature of Coaching Services

Coaching Is Not Psychotherapy

Dual Role Disclosure

Confidentiality and Its Limits

Communication and Boundaries

Emergencies and Crisis Care

Fees and Payment

Scope and Limitations

Transition to Therapy if Clinical Needs Arise

Client Responsibility

Sign and Submit

Your full name (typed signature)
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Your email
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Relationship to client
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Date
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I am providing my electronic signature on this form. By checking this box and clicking Submit, I agree my typed name above has the same legal effect as a handwritten signature, I intend to be bound by the terms of this document, and I have had the opportunity to print this document for my records.
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