COACHING INFORMED CONSENT AND DISCLOSURE DOCUMENT
Coaching is a partnership toward a common goal that relies heavily on honesty and trust. This document is designed to establish those qualities by disclosing your rights and responsibilities to the coaching relationship, and by informing you as to what you can expect from me.
Coaching is not therapy. Although my approach is based in Somatics (body-based), and some licensed therapists use similar techniques which emphasize your connection to your body, there are important differences between the two. Coaching focuses on your goals and how you can get there, and we only need to explore your past experiences in order to understand where things are for you now. Compared to coaching, therapy often focuses more on your history as a way of understanding it and healing past experiences, although it certainly includes looking for solutions to your current situation.
Somatic (body-based) coaching differs from many other kinds of coaching work in that it emphasizes your connection to your body. It also emphasizes the importance of experiences (as opposed to thoughts) as the central vehicle towards deeper freedom and choice.
While the focus of our work together is the improvement of your sexual and relational lives, there may be other areas of your life (i.e. work, school, family history, etc.), which inform your sexual and relational well-being. We may need to discuss these and other realms in order to help you move through relationship and intimacy blocks. I am NOT a licensed therapist and I am not required to be licensed in order to practice sex & relationship coaching in the State of Washington. Limits of my practice include: I can not diagnose organic or medical conditions of any nature, or prescribe medications for same. I also can not offer diagnoses for mental health conditions. If you need additional support from a practitioner with expertise in those areas, I would be happy to help you find someone.
MY RESPONSIBILITIES TO YOU AS YOUR COACH
You have the absolute right to the confidentiality in our work together. I will not tell anyone else what you have told me, or even that you are working with me, without your prior written permission. I will always act so as to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with whomever you choose, and you can change your mind and revoke that permission at any time.
If you elect to communicate with me by email or text message at some point in our work together, please be aware that these media are not completely confidential. All messages are retained in the logs of your and my Internet service provider, and text messages are recorded by your and my phone service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service or phone provider.
While coaching does not fall under the same mandated reporting requirements as therapy, I reserve the right to break confidentiality if I believe that you are likely to cause harm to yourself or someone else. I will inform you of any time when I think I will have to do so.
I have a consulting relationship with an experienced relationship coach and it is common practice for me to consult with her on my caseload. I also sometimes consult with other coaches to seek their input so that I can provide the best services possible. The only purpose of consultation is to ensure quality of care. I make every effort to protect your identity at all times in these settings.
2) RECORD KEEPING
I prefer to take some notes during and after our sessions, and retain them in your records, for both your protection and mine. In the state of Washington, you have the right to request that I not keep any detailed records. If you would like to exercise this option, please let me know, and I will present you with a written request to sign. You have the right to see your records, but you will need to give me 24-hour advance notice to supply them. Your records will be kept for 5-years after your last visit, at which point they will be destroyed. All reasonable precautions are taken to secure your records, and they are strictly confidential, with the following exceptions:
- Records are released with your written authorization, or that of your personal representative, should you become disabled or die.
- Records are released if you waive privilege by bringing charges against me.
- Records are released in response to a subpoena from the state secretary, in response to a regulatory investigation, and as required in cases of abuse, neglect, or harm to self or others.
3) TOUCH, CONSENT, AND OUR WORKING RELATIONSHIP
During our work together, there may be times when I invite you to experiment with yourself, your partner (if you are coming in as a couple), or with me around emotions, touch, intimacy and connection. All of these experiments are in service of you having a deeper understanding of your own internal process. Touch is only used with your informed consent, and only when you actively say yes. I will take silence, saying “maybe,” or any response other than a clear “yes” as a “no.”
Before we engage in any touch-based practice, I will describe and explain what I’m suggesting so that you can make an informed choice about exploring it, and so we can make any adjustments needed to make the exercise both safe and effective. You have the right to stop or change any touch or exercise in which we are engaging AT ANY TIME, for any reason. I will respond to your expressed boundary request respectfully and without question. I also watch for non-verbal cues and reserve the right to check in with you or stop an activity or exercise when I feel it is not serving you or potentially causing harm.
In order to maintain the container that supports the personal growth and healing work that we will engage in, we will not have any personal relationship while we are working together, and for at least two years after the termination of our coaching relationship. In this context, “personal relationship” includes friendship and social interactions. You are welcome to follow me on social media, with the understanding that it does not constitute a personal relationship.
Since I sometimes share social community with clients, it is possible that we might both attend the same event or have mutual acquaintances. If we see each other in public or social spaces, you are welcome to initiate a conversation with me, but I will not approach you or initiate contact.
Once two years since the completion of our coaching relationship ends, if you want to engage in a personal relationship of any kind, you are welcome to contact me to talk about it; however, I will not initiate that conversation. I will inform my supervisor and my accountability point person, Rachel Drake (see below), and we will discuss the situation and all relevant circumstances. If we agree that a personal relationship is appropriate and something that I am available for, you and I will have a series of conversations about what kind of relationship we want to create, and how we will transition our connection.
Navigating Pre-Existing Relationships
If you and I share professional circles, we will have an open and frank discussion before our first coaching session to talk about what we would each need to both support our work together and maintain an appropriate professional relationship.
If you and I have a pre-existing personal or professional relationship, we will have an open and frank discussion to explore if we can maintain our connection, if we need to shift entirely to a practitioner-client relationship, or if you would be better served by a different coach. That will depend on the nature of the concern or topic that you are seeking support for, the history that we share, and your motivations for approaching me. Your safety and needs will be prioritized through this process.
Codes of Ethics
As a certified somatic sex educator, I strive to abide by the Code of Professional Conduct and Ethics of the Association of Certified Sexological Bodyworkers in all of my somatic sex education sessions. As a certified Somatica® practitioner, I strive to abide by the Somatica Institute Code of Ethics in all of my coaching sessions. If you have any concerns, you can find information about how to contact my accountability point person, the ACSB, and the Somatica Institute below.
4) MY ACCOUNTABILITY PROCESS
In 2018, I initiated an accountability process to address harms I caused to one of my previous partners and to my personal and professional communities:
- From 2014-2016, I harmed and emotionally abused one of my partners.
- I used social media in the autumn of 2016 to defend my actions which harmed my communities.
- I took advantage of the power dynamics that come with being a speaker and workshop teacher.
My accountability pod and I launched our public process in June 2019, and we have been working as a group to create a safe space for people to report harm that I caused, and to move towards repair and resolution. My accountability pod and I have published a series of documents, in which we describe various aspects of this situation, and we will continue to do so until my process is complete. If you are interested in reading about this, here are some places to start:
- Medium account for posts about my accountability work (managed by my pod)
- My public statement and the pod’s public statement
- My pod members
- Accountability Pod FAQ
- Naming My Harms
- The Work I’ve Been Doing
- Confidential pod contact email (I do not have access to these messages)
I invite and welcome any questions or concerns about my accountability process or how it might affect our work together. If you decide that you would prefer a different practitioner, for this or any other reason, I fully support your choice and I would be happy to offer suggestions.
If you would like to contact my pod, you can send a confidential email to email@example.com. They will only share your message with me with your express, affirmative consent.
YOUR RIGHTS AS A COACHING CLIENT
You have the right to ask questions about anything that happens as part of our coaching work. I’m always willing to discuss how and why I’ve decided to do what I’m doing, and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful, so we might discuss my level of experience with the technique you have in mind. You can ask me about my training for working with your concerns, and can request that I refer you to someone else if you decide I’m not the right coach for you. Coaching is not therapy, so if your concerns would be better addressed by a therapist, I fully support that and can help you find a practitioner to work with.
You are free to end coaching at any time, for any reason. Usually, it will be up to you to decide when to discontinue working together. If, in my professional opinion, I am no longer serving your best interests, for any reason, including an exceeding of my competence, I will refer you to a licensed therapist or another qualified professional. If you do violence to, verbally or physically threaten, or harass my family or me, I reserve the right to terminate you unilaterally and immediately from coaching. If I terminate you from coaching, I will offer you referrals to other sources of care, but cannot guarantee that they will accept you as a client.
You have the right to refuse treatment, and the right to choose a practitioner and treatment modality that best suits your needs.
YOUR RESPONSIBILITIES AS A COACHING CLIENT
You are responsible for coming to your session on time and at the time we have scheduled. If you are late, we will end on time and not run over into the next person’s session. If you miss a session without canceling, or cancel with less than twenty-four hours notice, you must pay for that session before our next regularly scheduled meeting. The only exceptions to this rule are if you would endanger yourself by attempting to come (for instance, driving on icy roads without proper tires), or if you are having a genuine emergency. I reserve the right to assess the nature of your situation, determine whether it is a true emergency, and decide whether it qualifies as an exception to this policy.
2) ALTERED STATES
Coaching with me involves working together to help you access, observe, and process deeply emotional content as a resource for insight. You are responsible for coming to sessions “unaltered.” I have no judgment about your recreational activities outside of our time together, but the presence or residue of any drugs, alcohol, or the like in your system challenges our ability to reach those deep emotions in a way useful to our purpose. You will also not be permitted to use any substances by any means of delivery while in session. “Substances” include, but are not limited to alcohol, nicotine, marijuana, caffeine, benzos, narcotics, and psychedelics/hallucinogens. UNLESS substances are PRESCRIBED BY A MEDICAL PROFESSIONAL, and taken as prescribed, you will be asked to reschedule your session should your altered state become apparent. You will be charged full fee for the session.
My regular fee for a 60 minute session is a sliding scale of $150-300. Sliding scale means that you can choose what amount within that range is most appropriate for your circumstances. For longer sessions, the fee is prorated accordingly.
If my regular fee would make coaching sessions a hardship or impossible for you, I keep spaces available for people who need a lower rate, and I am happy to talk with you about what would make it feasible for us to work together. Please let me know if you would like to discuss this so we can find a way to make coaching accessible to you.
You are responsible for paying for your session at the time of service, unless we have made other arrangements in advance. I do not accept insurance, but will accept cash, personal checks, and credit/debit cards. I also accept PayPal (https://www.paypal.me/charlieglickman) and Venmo (https://venmo.com/charlieglickman).
You will be surcharged $25.00 each for the first two checks returned for insufficient funds; thereafter, I will not accept your check. I am not willing to have clients run a bill with me. I cannot accept barter for coaching, nor can I take DSHS medical coupons. Any overdue bills will be charged 1.5% per month interest.
I am not a licensed therapist and therefore, I am not part of any in-network insurance panels and you should not expect any of the services to be covered or reimbursed by insurance or through a flexible spending account. You assume full responsibility for and agree to pay all costs, charges, and expenses for services rendered under this Agreement.
5) COMPLAINTS & CONCERNS
There are no guaranteed results in coaching. If you’re unhappy with what’s happening in our work together, I hope you’ll talk about it with me so that I can respond to your concerns. I will take such feedback seriously, and with care and respect.
You are also free to discuss your complaints about me with anyone you wish, and do not have any responsibility to maintain confidentiality about what I do that you don’t like, as you are the person who has the right to decide what you want kept confidential.
If you have had an experience with me that you believe violates any of these policies, or that you felt harmed by, I would be happy to talk with you about your concerns or your experiences. I also recognize that it can be difficult to initiate that discussion. If you have any hesitation in approaching me, I invite you to contact my accountability point person, Rachel Drake. Rachel is a member of my accountability pod and you can read about her below. Rachel will only share information with me about your concerns or your identity with your express, affirmative consent.
Rachel Drake (she/they), has a passion for helping people make breakthroughs and uncover their power. She is a Success Coach, Accountability & Consent Consultant, speaker, educator, and author. Rachel is a founder of and served as the Deputy Director of the Consent Academy, a Seattle-based 501c3 non-profit, which she helped found in 2016. She is excited about the reception of The Consent Primer, Foundations for Everyday Life, released in 2019, the first “how-to” guide about consent which she co-authored with the Academy. She has held numerous leadership positions over the years in the arts and sex positive community, in addition to educating and coaching adults since 1998. In the mid 2000’s she honed in on her passion for healthy consent, sex and non-traditional relationship dynamics. Since then she has helped thousands of people transform their lives, find success and personal freedom. Rachel is currently working on her degree in Applied Behavioral Science and her first solo book project, “Transformative Accountability: A Roadmap for Lasting Change”.
You can also contact the Association of Certified Sexological Bodyworkers with any concerns about my somatic sex education sessions, and you can contact the Somatica Institute with any concerns about my coaching sessions.
6) HEALTH; CONSENT TO TREATMENT
By accepting the terms of this Agreement, you voluntarily consent to coaching, treatment, or evaluation performed by me, with the understanding that I am not a licensed therapist. This consent for treatment is valid for all services that are provided from the date that you sign this Agreement until services are terminated. You understand that you can revoke this consent for treatment at any time in writing (an email can serve this purpose) to me.
You represent that you are physically and mentally sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent you from receiving the services or that would risk your health or well-being while receiving the services. You agree to notify me of any changes in mental or physical health or life circumstances that may affect your treatment.
7) ASSUMPTION OF RISK; LIMITATION OF LIABILITY
You certify that you voluntarily agree to receive these services. You understand and acknowledge that sex and relationship coaching is not therapy and, by its very nature, carry with it certain inherent risks that cannot be eliminated. You understand and acknowledge that, regardless of the care taken by me, I cannot guarantee your safety, health or well-being, or any specific results. You expressly assume and accept sole responsibility for your health and safety and for any and all injuries that may occur. You understand that you must inform me of any medical conditions, medications or other factors that may affect your ability to safely receive the services.
You agree that to the fullest extent permitted by law, I shall not be liable to you for any injury, harm, loss or damage that you may suffer as a result of your receiving the services or of any activity contemplated by this Agreement. You hereby agree to waive any claim against me for any injury, harm, loss or damage that you may suffer as a result of your receiving the services or of any activity contemplated by this Agreement.
You agree to hold harmless and indemnify Charlie Glickman and Charlie Glickman LLC from all claims (whether initiated by you or by a third party) and to reimburse them for any expenses incurred as a result of your involvement with me or receipt of my services.
9) TREATMENT REFUSAL/TERMINATION
You acknowledge that you have been informed that at any time you can suspend or refuse to implement any and all recommendations or instructions made by me. You agree to maintain awareness of and keep all of your physical and emotional boundaries. Additionally, you will inform me within a reasonable time if anything happens during a session that makes you feel uncomfortable.
The ongoing commitment to the relationship between you and me will always be treated with utmost importance. I will make every effort to maintain a mutually healthy working relationship and I ask you to do the same. That being said, either your or I are free to terminate this agreement at any time, for any reason. If you would like to continue coaching or start some form of therapy with a different practitioner, I will make every effort to assist with that transition.
By accepting this Agreement, you acknowledge that you have carefully read it and understand that includes a complete and absolute release of liability. You agree that you have knowingly agreed to receive the services and that you have been given an opportunity to ask questions regarding the Agreement and the services.