Date; 5 Sep 2020
The purpose of a disclosure statement is to provide explanatory information regarding the significant features of the client-practitioner agreement to enable the client to make an informed decision regarding purchasing of couple coaching services.
Coach Disclosure Statement
Hendrik J Ensing
Rock Solid Relationships
383 Karakariki Road
Hamilton 3289, new Zealand
This is a statement of your rights and responsibilities for our therapeutic relationship. I provide this written disclosure of the following information to clients before coaching begins. Please read this statement thoroughly and then sign the consent for treatment on the Client/Practitioner Agreement. If you have any questions or concerns, please tell me and I will be happy to discuss them with you.
Client’s Rights and Responsibilities
Clients have the right to choose a couple coach who best suits their needs and purposes. Clients may ask questions about treatment at any time and may choose to terminate therapy at any time.
B.Ed University of Waikato
Associate of Science degree, BYUH 1995.
Post Graduate studies in Conflict Resolution 456, University of Waikato 2019
My practise is eclectic, that is, it integrates many different therapeutic styles and techniques depending on what fits best with the client and situation. Some of these include an externalising, narrative approach to conflict resolution. I focus on client’s strengths and help them find solutions that work within their systems so that they are maintainable over time.
Clients can rely on me to maintain confidentiality regarding our work together with these few exceptions:
1) In supervision I may consult with other therapists, who are required to keep client information confidential, for case consultation purposes, and in doing so will not mention names of clients.
2) When abuse or neglect of a child, dependent adult, or developmentally disabled person is present, this will be reported.
3) Others be informed if a client threatens to harm herself/himself, or others. If that threat is perceived to be serious, the proper individuals must be contacted: this may include the individual against whom the threat is made.
4) In the event of a court order, couple coaches may be required to disclose information in the presence of a judge.
5) Information which may jeopardize my safety will not be kept confidential.
6) In the event of a medical emergency, emergency personnel may be given necessary information.
7) If you bring a complaint against me with the courts or police, Department of Health, information will be released.
8) In the event of the client’s death or disability, the information may be released if the client’s personal representative or the beneficiary of an insurance policy on the client’s life signs a release authorizing disclosure.
Regarding Court Requirements
It is my policy NOT to provide clinical evaluations or assessments of the quality of client participation when clients are accessing couple coaching to fulfill court requirements or for other legal purposes.
Coaching fees are dependent upon household income and payable in full at time of service. Please read the Rate Fee Schedule in the FAQ on this website. These fees are for a 50 minute coaching session as well as 10 minutes for case note preparation. Please be aware that I usually charge clients for missed sessions unless the client gives 24 hours notice.
A treatment plan will be developed with your agreement.
Consent for Treatment
Disclaimer : I am not a member or affiliated with the NZAC, NZCCA even though I aspire to the code of ethics in these organizations. My student membership in Resolution Institute, though current at time of writing, may laps at a future time for any reason including failure to pay fees on time. I also aspire to comply with the code of ethics of Resolution Institute as well as aspire to have indemnity insurance to cover my practise.
With my signature on the Client/Practioner agreement, I acknowledge that I have read and understand this disclosure. I consent to therapy with Hendrik Joseph Ensing, Couple Coach, according to the terms described here.