Client Consent Form Name * First Name Last Name Email * Please read the following and agree to the terms by checking the boxes below each statement. Marcia Haarer is licensed as a Master of Social Work Clinician in the state of Michigan. Any practice that she does via Video Calling outside of the state of Michigan is done as the capacity as a Consultant rather than as a Therapist. This means that if the client has mental health issues that need to be addressed, the client bears responsiblity for finding a licensed mental health practitioner in their state or country of origin to be responsible for those issues. This includes medication for mental health issues, and symptoms of suicidality. The American Psychological Association defines suicidality as “the risk of suicide, usually indicated by suicidal ideation or intent, especially as evident in the presence of a well-elaborated suicidal plan.” It can also be defined to include suicidal thoughts, plans, gestures, or attempts. I Understand and Agree Fee Agreement in compliance with the "No Surprises Act": If a client comes for Coaching for a total of ten sessions, at the rate of $200/session, they would pay a total of $2000 for the ten sessions. Unless a reduction has been arranged in the consultant/client relationship. Ten sessions is a realistic estimate to address a single issue in goal focused coaching plan. Issues of more complexity would require more than ten sessions and therefore would add to the overall price. I Understand and Agree Thank you!
