Consultation Documents - Jodi Carlton, MEd, LLC

NEW CLIENT CONSULTATION FORMS

If you have a Private Initial Consultation scheduled with Jodi Carlton, please complete the following forms. Your information is confidential and will be securely stored and accessible only to Jodi Carlton, MEd, LLC!

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PARTICIPATING ADULTS INFORMATION – Step 1 of 6

Name

First

Last

Mobile Phone

SMS Consent

May we send text communication to your mobile number for appointment reminders or to contact you about your consultation (we will not send you spam or marketing texts):

Indicate your Preference Below

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

This consultation is in reference to (please select all that apply):

My Marriage or Domestic Relationship
My adult child (over 18)
Myself

Who will be participating in this consultation in addition to you (please select all that apply)?

My Spouse/Partner
My Adult Child
I’m not sure

Your Partner's Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please indicate the primary person responsible for payment (and for correspondence regarding payment).

FEES AND PAYMENT POLICY

PAYMENT IS DUE AT THE TIME OF BOOKING YOUR APPOINTMENT AND MUST BE RECEIVED WITHIN 48 HOURS OF BOOKING IN ORDER TO AVOID APPOINTMENT CANCELLATION.

If you are unable to pay by credit card, please contact us directly to send you an invoice to pay by ACH bank draft. If paying by bank draft, payment is due upon receipt of your invoice.

APPOINTMENT CANCELLATION POLICY:

These services are not covered by insurance, but some flexible spending accounts or health savings accounts may provide reimbursement. It is your sole responsibility to determine your coverage. Jodi Carlton, MEd, LLC will not file any insurance forms on your behalf, but will provide proof of services and payment.

By entering your credit card information, making payment, or otherwise booking, electronically, or otherwise, a consultation, evaluation, a coaching group, course, or intensive coaching program, you are entering into a legally binding agreement with Jodi Carlton, MEd, LLC to receive services according to the following terms and conditions:

Failure to Pay: In the event that you fail to make any payments due in accordance with the terms, or do not perform obligations according to these terms, Jodi Carlton, MEd, LLC may terminate services immediately without notice and may also commence proceedings to collect any outstanding debts owed.

I agree that my credit card may not be refunded for any appointment that is not canceled at least 48 hours prior to the scheduled appointment.

Yes, I agree to this policy.

WARRANTIES AND REFUNDS

Jodi Carlton, MEd, LLC represents and warrants:

(a) in providing the services, she will comply with all law and industry standards to the best of her knowledge;

(b) the work performed will be done to a high standard in accordance with best practices for coaching professionals; and

(c) the scope of the services will be limited to the description provided in these terms. Similar or equivalent services may be substituted from time to time if, in the sole opinion of Jodi Carlton, MEd, LLC, it would benefit you or be required to meet the terms.

You represent and warrant:

(a) that you will provide all relevant information required for Jodi Carlton, MEd, LLC to carry out the terms.

APPOINTMENTS AND CANCELLATIONS Please remember to cancel or reschedule 48 hours in advance.

Cancellations and re-scheduled appointments will be subject to a full charge if NOT RECEIVED AT LEAST 48 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. Appointments will begin promptly at the time you are scheduled. If you are late for an appointment, you may lose some of that session time. You acknowledge and agree that upon execution of these terms to be responsible for the full extent of the agreed-upon fee.

Refunds for cancellation or termination of services for any reason whatsoever are issued at the sole discretion of Jodi Carlton, MEd, LLC.

CHARGEBACKS:

Chargebacks without Jodi Carlton, MEd, LLC’s prior written consent are not authorized.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Jodi Carlton, MEd, LLC in writing of any changes in my account information or termination of this authorization.

I certify that payment will be made by an authorized user of the credit card provided and that I will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form.

Signature

CONFIDENTIALITY POLICY

All information shared will remain confidential. If you share something with Jodi Carlton, MEd, LLC without your partner or adult child present, it will not be disclosed to the absolute best of her ability. At times, she may encourage you to share information with your partner or adult child that she deems critical. However, she will not disclose information you have shared without your consent.

On occasion, general information from a private session may be shared to teach in a public forum, but your names, details, and other identifying information will never be shared.

You are free to share anything that has been discussed during your private consultation or coaching.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best services for you. Information about you may be shared in this context without using your name or other identifying information.

In our interactions outside of coaching, such as in social media groups, your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, you are free to share what you choose.

LIMITS TO CONFIDENTIALITY

The consultation and coaching content and all relevant materials will be held confidential unless you request in writing to have all or portions of such content released to a specifically named person/persons.

Limitations of client-held privilege of confidentiality exist and are itemized below:

If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If I, Jodi Carlton, MEd, have a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.
Suspicions, as stated above, in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties who are minors, or otherwise unable to self-advocate due to cognitive or developmental limitations.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If by order of a court of law, or if information is shared for the purpose of rendering an expert’s report to an attorney. I caution you not to plan for me to be an expert witness, or to provide a written affidavit without discussing it with me. There are significant risks to involving a coach in legal affairs.

You may request a copy of your records which includes your appointment dates, fees, and participants, as well as a copy of these consent documents. You will not be provided with Jodi’s personal notes about you or your partner.

SECURITY AND PRIVACY:

All payment and personal information will be kept in a secure manner in accordance with United States and European privacy requirements.

Signature

CONSENT FOR SERVICES (Part 1)

Consultation and evaluation is unique in that it is a highly personal and at the same time, a contractual agreement. It is important for us to have a clear understanding about how our relationship will work, and what each of us can expect.

You have taken a very positive step by deciding to seek consultation. The insight and guidance that Jodi Carlton will provide depends largely on your motivation and willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc.

There are no miracle cures or quick-fix solutions. Jodi Carlton cannot guarantee that your life or relationships will change as a result of services she provides to you. She can promise to provide you her expert opinion and guidance to help you get clarity and to identify solutions for your relationship.

YOU CAN EXPECT THE FOLLOWING FROM JODI CARLTON:

To provide direction, encouragement, and support in a non-judgmental environment.
To provide observations and direct feedback based on expertise and experience.
To listen carefully to what you say, and to make recommendations based on your individual and/or relationship goals.
To use assessment instruments that are of a professional industry standard.
To provide you with a verbal explanation of any applicable assessment data.
To provide implementable, and actionable methods and strategies for meeting your personal and/or relationship goals.
To provide honest and professional expertise regarding your skills and abilities.
To be forthcoming regarding any dysfunctional, harmful, or abusive behavior that is witnessed or observed.
To set boundaries regarding any harmful or abusive behavior that is experienced by Jodi Carlton directly from any client.
To be respectful of your personal values, beliefs, wishes, and preferences.

JODI CARLTON EXPECTS THAT YOU WILL:

Commit yourself to intentional curiosity and discovery.
Provide honest and truthful information.
Be open to receiving Jodi Carlton’s observations and guidance about your personal traits, characteristics, and behaviors.
Conduct yourself on video calls and in messages with care and respect, and without harassment or verbal attacks/abuse toward your partner or Jodi Carlton.

OUTCOMES

You are solely responsible for your own physical, mental, and emotional well-being, including decisions, choices, actions, and results arising out of, or resulting from, this consultation/evaluation and coaching program. As such, you agree that Jodi Carlton, MEd, LLC and associates are not, and will not be, liable or responsible for any actions or inaction, or for any direct or indirect result of any services provided. Your choice, effort, and motivation to participate in this consultation/evaluation and coaching program, and to follow, or not follow, the subsequent guidance received, is entirely your responsibility. The outcomes that you seek are not guaranteed.

Unhappiness or dissatisfaction with Jodi Carlton’s professional expertise or coaching methods is NOT grounds for a refund.

If Jodi Carlton, MEd cancels or terminates your consultation or evaluation for reasons that are related to her own inability to provide you the agreed-upon services, she will determine a refund amount based on the amount of services you have/have not received.

Please check the box below:

I have read, understand, and consent to the expectations outlined above.

CONSENT FOR SERVICES (Part 2)

CONTACT BETWEEN SESSIONS

If you need to contact Jodi Carlton between appointments, please leave a message on our voicemail at 770-685-7973 or email us at gethelp@jodicarlton.com. Our staff responds within 24 hours. If a true emergency situation arises, please call 911 or your local/regional emergency number. JODI CARLTON DOES NOT PROVIDE EMERGENCY MENTAL HEALTH SERVICES OF ANY KIND.

SOCIAL MEDIA

Due to the importance of your confidentiality, Jodi Carlton does not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). You are free to follow Jodi Carlton on social media or join private social media groups.

ELECTRONIC COMMUNICATION

Jodi Carlton cannot ensure the confidentiality of any form of communication through electronic media, including text messages.

There are potential risks, consequences, and benefits of electronic communication. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, better access to coaching, better continuity of care, and reduction of lost work time and travel costs.

When using electronic communication in consultation, evaluation, and coaching services, potential risks include, but are not limited to Jodi Carlton’s inability to make visual observations of potentially relevant issues such as: your physical condition, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include Jodi Carlton not being aware of what she would consider important information that you may not recognize as significant to present verbally.

RELATIONSHIP

The relationship under these terms is that of principal and independent contractor. These terms do not make either party a joint venturer, partner, employee or agent of the other. No act or omission of either party is to bind the other party except as expressly set out in these terms.

Non-Disparagement: If a dispute arises, both parties agree that confidentiality is paramount to your reputation and to Jodi Carlton, MEd. At no time will any communications or discussions be made public. This includes but is not limited to any social media websites of either party. Public discussion or comments about either party are considered defamatory, negative or otherwise damaging and will be the subject of compensation in any mediation or litigation claim.

Arbitration: In the event of any dispute on the work, quality or ownership that cannot be resolved, both parties agree to obtain an independent professional arbitrator/dispute resolution specialist to make a determination on the dispute and each of us agrees to pay our own costs.

OWNERSHIP OF INTELLECTUAL PROPERTY

Ownership of Intellectual Property and Confidential Information: All materials and work is provided without warranties of any kind, both express and implied. Any design, materials, analyses, processes, discussions and other intellectual property, both tangible and intangible, which is provided or may be developed as a result of or during coaching is and will remain the property of Jodi Carlton, MEd, LLC at all times. No materials may be reproduced or used for any purpose other than personal and private use. You shall not be authorized to use any of Jodi Carlton, MEd, LLC’s intellectual property for business purposes. Authorization to share, copy, distribute, or otherwise disseminate any materials received from Jodi Carlton, MEd, LLC electronically or otherwise is not provided without the prior written consent of Jodi Carlton, MEd, LLC.

This agreement is not transferable or assignable without Jodi Carlton, MEd, LLC’s prior written consent.

LIMITATION OF LIABILITY, INDEMNITY, DISCLAIMER OF GUARANTEE

Indemnification: Jodi Carlton, MEd, LLC is in no way liable for any loss or damages whether direct, indirect or consequential which you may suffer in reliance directly or indirectly on all or any part of these services. You shall indemnify and hold harmless Jodi Carlton, MEd, LLC, and her representatives from and against any and all actions, claims, liabilities, proceedings or demands which may be brought against them in respect of any loss, death, injury, illness or damage (whether personal or property and including reasonable legal fees and expenses).

Liability Terms: The liability of Jodi Carlton, MEd, LLC, is governed solely by United States Consumer Law and these Terms. Any other conditions and warranties which may be implied by custom, law or statute are expressly excluded.

Own Risk: You acknowledge and agree that you use these services at your own risk, and agree they are liable for and agree to indemnify and hold harmless Jodi Carlton, MEd, LLC, and her representatives, for and against any and all claims, liabilities, actions and expenses which may result either directly or indirectly from a breach of these Terms, misuse of the Services or in connection with any of the Services.

NO SUBSTITUTE FOR OTHER PROFESSIONAL SERVICES

Medical Services: Services may involve health or other personal management discussions. Consultation and evaluation services should not replace discussions with other qualified healthcare or other relevant professionals and should not be used to diagnose or replace any professional treatment or management of any condition. You are at all times responsible for your own physical health and emotional well-being and are responsible to seek medical treatment (including, but not limited to psychotherapy), if needed. Jodi Carlton, MEd, LLC does not provide psychotherapy services. The organization is not responsible for any decisions made as a result of services. Pre-existing conditions must be treated by a medical professional and any information provided is not to be relied on in substitution. You understand that you therefore engage the Services at your own risk.

Legal Discussions: Some of the Services may involve discussions about legal options and choices, particularly related to separation and divorce. Services provided by Jodi Carlton, MEd, LLC should in no way replace discussions with qualified legal counsel.

CHOICE OF LAW/VENUE

This Agreement shall be governed by and construed in accordance with the laws of the State of Georgia without giving effect to any principles or conflicts of law. pursuant to the rules of the American Arbitration Association, which arbitration shall be binding upon the parties and their successors in interest. The prevailing party is entitled to be reimbursed for all reasonable legal fees from the non-prevailing party in order to enforce the provisions of these terms.

Signature

NEW CLIENT CONSULTATION FORMS

SMS Consent

SCOPE OF SERVICES

FEES AND PAYMENT POLICY

APPOINTMENT CANCELLATION POLICY:

WARRANTIES AND REFUNDS

CONFIDENTIALITY POLICY

LIMITS TO CONFIDENTIALITY

SECURITY AND PRIVACY:

CONSENT FOR SERVICES (Part 1)

CONSENT FOR SERVICES (Part 2)

CONTACT BETWEEN SESSIONS

SOCIAL MEDIA

ELECTRONIC COMMUNICATION

RELATIONSHIP

OWNERSHIP OF INTELLECTUAL PROPERTY

LIMITATION OF LIABILITY, INDEMNITY, DISCLAIMER OF GUARANTEE

NO SUBSTITUTE FOR OTHER PROFESSIONAL SERVICES

CHOICE OF LAW/VENUE

Courses & Services

Assessments & Quizzes

Important Links