Center for the Challenging Child

Client Coach Agreement

Please print, sign, date, and bring this to your first appointment at
2233 University Ave West, #325, St. Paul, MN or email it to tina@parentingmojo.com.

What You Can Expect from Your Coach:
1. I will provide an initial 1.5 hour intake and 60-minute parent coaching sessions on a regularly scheduled basis, beginning with four total sessions, and as needed after that.
2. I will use my knowledge and experience for the betterment of your parenting relationship at all times. I will hold your family as a highly valued, healthy entity.
3. I will be open for brief troubleshooting phone calls between coaching appointments.
4. I will not do therapy, as I am not a licensed therapist in my role as coach. Rather, I will coach you on the specifics of applying Present Moment Parenting in your home or classroom. I will celebrate your successes with you!
5. I will refer you to a therapist if it is determined to be necessary. Our parent coaching relationship may continue during the time that the therapy is taking place. If coaching does continue, we acknowledge that it is training in a specific set of skills, and is complementary to the therapy.
6. I will respect your privacy, while sharing the limits of confidentiality with you.

What Your Parent Coach Will Expect from You:
1. You agree to participate in each parent coaching appointment at the designated time.
2. You agree to cancel or reschedule your appointment 24 hours in advance if your plans need to change. Call your parent coach at 651-453-0123 or email tina@parentingmojo.com to reschedule.
3. You agree to report three successes to your coach at the beginning of each session. This is intended to keep you focused on success with the child.

Your Rights as a Client
1. To expect that your coach has met the qualifications, and has training, and experience for competent practice.
2. To request information regarding the credentials of your coach.
3. To a grievance process. Please call 1-877-287-2441.
4. To privacy as defined by policy and law.
5. To be free from discrimination on the basis of race, religion, gender, or other unlawful category..
6. To have access to records completed by your coach according to Anu Family Services’ policy.
7. To insert information into your client file.
8. To be free from exploitation for the benefit or advantage of your coach.

Confidentiality
Center for the Challenging Child maintains a strict policy on the confidentiality of your records. Information will only be shared once you have given your permission via a signed Release of Information.

Following are some circumstances in which we are required by law to release information:
If your coach becomes aware that you may be a danger to yourself or others.
If your coach becomes aware of child abuse or neglect.
If your coach is subpoenaed to court to testify or your records are subpoenaed by the court.

I have reviewed and understand the information above.
Parent Signature _____________________________________________ Date ________________
Parent Signature _____________________________________________ Date ________________
Parent Coach Signature ________________________________________ Date_________________

Admin Use Only Egnyte path ( )
file: CCC Client/Coach Agreement v 6.3.13
Coach forward to office administrator upon completion

Clients’ Rights

As required by HIPAA privacy regulations, this notice describes how protected health information about Center for the Challenging Child (a division of Anu Family Services, Inc.) clients may be used and disclosed, and client rights to access and amend their information. The following policies and procedures are based on HIPAA Privacy requirements and applicable Minnesota State Law. Please review it carefully. This Notice was first in effect on April 13, 2003 and was revised effective October 8, 2013.

Client Rights
Center for the Challenging Child is permitted to use and disclose protected health information (PHI) for treatment, payment and health care operations, as described in the following examples:

1. For treatment – (example, multidisciplinary team case consultation).
2. For payment – (examples: determining a client’s insurance eligibility or coverage, obtaining prior authorization from an insurance company for a service, or billing a client’s insurance for a service provided).
3. For health care operations – (examples, outcomes evaluation or quality assessment activities).

Center for the Challenging Child is permitted or required, under specific circumstances, to use or disclose protected health information without written authorization from the individual. (If a use or disclosure for any purpose prescribed in the Privacy Regulation is prohibited or materially limited by applicable Minnesota State law, the description of such use or disclosure reflects the more stringent law.)

An “individual” refers to an individual client or to the parent/legal guardian of a child client.

Anyone who does not wish to receive these materials may opt out at any time by notifying the Marketing and Development Office at info@anufs.org or by calling (715) 629-9236 extension 406.

Other uses and disclosures will be made only with the individual’s written authorization and the individual may revoke such authorization.

1. Individuals may be contacted for appointment reminders.
2. Center for the Challenging Child does not solicit clients currently receiving services from the agency. Agency newsletters may be sent to clients.

Individuals have the following rights regarding protected health information; the extent of and exceptions to these rights are defined in the Privacy Regulation:

1. The right to request restrictions on certain uses and disclosures of protected health information. Center for the Challenging Child is not required to agree to a requested restriction, however.

2. The right to receive confidential communications of protected health information, as applicable.

3. The right to inspect and copy protected health information as applicable.

4. The right to amend protected health information, as applicable.

5. The right to receive an accounting of disclosures of protected health information, as applicable .

6. The right to obtain a paper copy of the Notice from the covered entity upon request. This right extends to an individual who has agreed to receive the Notice electronically.

Federal and State laws grant clients of this Agency the right to strict privacy in regard to information about themselves. This means that no information by which a client could be identified will be given by us to anyone else at any time without written consent of the individual, unless specifically required or permitted for treatment, payment, or health care operations purposes by law.

Important exceptions are that center staff members are required by law to report suspected abuse and neglect of children or vulnerable adults and records may be subpoenaed if a client is involved in a court action.
Individuals are not required to give any information about themselves. However, refusal to give needed information will hamper service planning. The information that is requested about clients is needed for one or more of the following reasons:

1. To help us evaluate clients’ needs for services and develop a plan to meet those needs;
2. To determine financial eligibility for reduced service fees;
3. To meet Federal, State, and Local statistical requirements. Rev 10-08-2010

Client Grievance/Complaint Procedure

No audio or video recording of a treatment session will be made without client permission.

No one except Center staff involved in treatment will view or listen to a treatment session or recording of a session, or read a verbatim transcript of a session unless the client gives permission.

Individuals have the right to view their protected health information, with a few exceptions:

1. If a doctor or licensed provider believes that it will be harmful to the client or others.
2. Information compiled in anticipation of, or for use in, a civil, criminal or administrative action or proceeding.

Clients may have the information explained to them by an agency coach and may request corrections, additions, or amendments to any information in their client record. If individuals have any questions about data privacy or client privacy rights, they may contact the agency’s privacy official or their coach.