Parent Coach Consent Agreement

Parent Coaching Agreement(Required)
You are required to read through the following terms and conditions. When you have reach the end, checking the box will satisfy the agreement to be submitted.


The Parent Coach and the Parent(s) enter into this contract voluntarily.


A. Role of the Parent Coach: The Parent(s) understand that the Parent Coach’s role is to facilitate conversations which promote parent growth in three primary areas: education and assimilation of information about child development and positive behavior management; communication skill-building; and self-awareness / self-care. The Parent Coach will listen carefully, ask key questions and give insightful feedback that promotes the awareness and skills necessary for successful implementation of positive strategies leading to fulfillment of parenting and co-parenting goals. Additionally, the Parent Coach may offer supplementary resources. The Parent Coach is not serving in the role of a therapist. If the Parent Coach de- termines that psycho-therapeutic interventions would be helpful for the Parent(s), the Parent Coach will make a referral to an appropriate therapist or terminate the Parent Coach Con- sent Agreement and enter into a Therapy Consent Agreement with the Parent(s).

B. Role of the Parent(s): The Parent(s) understand that the Parent(s)’ role is to answer the Parent Coach’s questions as completely and honestly as possible, to engage to the fullest extent possible in the coaching process, to follow through with the positive strategies to the best of the Parent(s)’ ability, and to give feedback to the Parent Coach as completely and honestly as possible regarding the coaching process and the implementation of the select- ed strategies.

C. Collaboration between Parent Coach and Parent(s): The Parent(s) understand that Par- ent Coaching is a collaborative process in which the Parent Coach and the Parent(s) work together to co-create the Parent(s)’ goals for parenting, for communication, for self-care and for the coaching process.


A. Appointments: Appointments with the Parent Coach shall be scheduled at the request of the Parent(s) by phone, by email or in person. Coaching sessions may take place in person
or over the telephone. Standard appointments are 60 minutes in length, and the Parent(s)
may request additional coaching over the telephone or by email.

B. Communication: The Parent(s) may contact the Parent Coach by telephone, email or text message. The Parent Coach will respond within 24 hours.

C. Confidentiality: All communication between the Parent Coach and Parent(s) is confiden- tial. Any sharing of information between the Parent Coach and any other party requires an authorization form signed by the Parent(s) giving written permission for a release of informa- tion. Either parent may request a conversation or meeting with the Parent Coach without the knowledge or consent of the other parent. All communications between the Parent Coach and the parent(s) will be private and confidential unless a release of information has been signed and submitted to the Parent Coach for the purposes of communicating with other parties.

D. Cancelled or missed appointments: The Parent(s) shall pay in full for any cancelled or missed appointments unless 24-hour cancellation notice is given.


Parent(s) shall pay for appointments at the time of service. Alternative arrangements may be made at the request of the Parent(s). Fees for appointments are $180.00 per hour. Fees for additional time spent in telephone or email conversations are billable at $180.00 per hour, calculated at 5-minute intervals. Parent Coach will notify the Parent(s) before any charges are accumulated for telephone or email conversations. Parent Coach shall bill the Parent(s) monthly with an itemized statement for telephone and email coaching.


Parent(s) understand that the Parent Coach is obligated under law to disclose the following information to appropriate authorities: 1) allegations of abuse or neglect of a child, 2) threats of harm to other people or yourself, 3) statements made indicating plans to carry out or hide an ongoing crime, and 4) statements made that reveal a felony crime.

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951 High Street Suite B Worthington, Ohio 43085