Client Agreement & Consent
This agreement (“Agreement”) made and entered by and between Cathay Psychological Institute (or “Company”), a California LLC, and their employees and agents (collectively referred to as “CPI” or “Company”), and the individual or entity, or representative or agent of client or entity, specified as recipient of the consultation (collectively referred to as “Client” or “You”) and is effective as of the date specified in the first booking confirmation (the “Effective Date”).
1. General Policies
Appointments. When scheduling an appointment or setting up an appointment on Company’s web site or portal, please provide the client’s name, phone number, email address, and chief reasons for consultation. Please try your best to be on time since the appointment must end on time. We ask that payments be made prior to any scheduled appointments.
Appointment Notice and Cancellation Fee: Company requires at least 48 hours’ advance notice prior to cancellation of any scheduled appointment. If you miss your scheduled appointment, or cancel with less than the above advance notice, Company will charge a cancellation fee in the amount of 50% of the appointment fee. You hereby authorize the charge of the consultation by signing up for a consultation via The Company site.
Online and phone communication; Electronic signatures. Company stores client records digitally, including recordings when applicable. While Company keeps the data secure according to legal requirements, and maintains the privacy and confidentiality of client data, you understand that no system is 100% secure. Consultant may communicate with client over the phone, email, or over videoconferencing technology. Anticipated benefits include improved access to Consultant and allows for Consultant and client to communicate while in different physical locations. Potential risks include gaps of failures in communication, complicating Consultant’s recommendations and advice, notwithstanding reasonable efforts to ensure the quality and reliability of transmitted information. There may be limitations to image quality or other electronic problems that are beyond the control of Consultant. Despite reasonable security measures, online communications can be forwarded, intercepted, or even changed or falsified without my knowledge. In addition, the information transmitted to Consultant may be insufficient for Consultant to provide proper recommendations and advice. Client agrees that an electronic entry of their name when booking acts as the legal equivalent of a manual signatures on this Agreement, and manifest consent to be legally bound by this Agreement’s terms and conditions.
Not a Medical Service Provider: Company is not a medical provider and may not provide medical advice or treatment. You should seek medical treatment, care, and follow-up with a licensed medical provider. You agree that you are not engaging Consultant for any medical services. You understand that Consultant does not diagnose, treat, or claim to cure any medical condition, and that Consultant’s services are not designed to replace conventional treatment methods of medical conditions.
2. Insurance Practices and Client Financial Responsibility
Payment: Company accepts various credit cards. Company bills to your debit or credit card on file unless you provide alternate payment information and instructions.
Fees. The cost for telephonic and video chat consultations are indicated in our Plans and Packages section.
No Participation in Insurance Plans or Medicare: Company does not participate in any insurance panels and does not accept assignment from any insurance company at this time. Consequently, you are responsible for payment in full at time of service and charges are determined by Company.
No Responsibility to Determine Eligibility for Benefits: Company is not responsible for determining eligibility for benefits or for assisting you with collecting insurance benefits and has no responsibility to correspond with or telephone or email any insurer.
My Financial Responsibility: I understand that Consultant does not accept insurance or negotiate with insurers, and that Consultant’s services are not reimbursed by any insurer. I am financially responsible for my session and agree to pay the charges incurred. Consultant does not accept partial payment or waive payment. I also agree to be responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for Company to take action to secure payment of an outstanding balance.
3. Miscellaneous Term and Termination.
This Agreement shall commence upon the Effective Date and shall continue until terminated unless a term has been specified on the signature page. Records will be maintained for one (1) year after the termination of the Agreement and thereafter returned to the client upon request or destroyed. If there is a dispute, or potential dispute, regarding payment Company will retain any applicable records concerning the dispute beyond the 1-year period.
Professional Liability Insurance. Company shall maintain professional liability insurance.
Indemnification. Client will indemnify, hold harmless and timely defend Company and its officers, directors, employees, agents, successors and assigns (each, an “Indemnified Party”) from and against any and all claims, demands, legal proceedings, administrative inquiries, investigations and proceedings, damages, losses, judgments, taxes, settlements, fines, penalties, remedial actions, costs and expenses (including attorneys’ fees) asserted against, incurred or sustained by any Indemnified Party, whether or not separately insured, that arise out of or results from or in connection with the work provided for in this Agreement.
Representations and Warranties. Client hereby represents, warrants and covenants that: (1) it has the power, authority and capacity to execute, deliver, and perform its obligations under this Agreement; (2) Client has conducted its own independent due diligence regarding the desirability of entering into this Agreement.
Nature of the Relationship. Nothing in this Agreement shall be construed or deemed to constitute, create, give effect to or otherwise recognize a joint venture, partnership, nor business entity of any kind.
Amendments; Waiver; Severability. No amendment, modification, waiver or discharge of any provision of this Agreement shall be valid unless made in writing and signed by an authorized representative of the Party against whom enforcement is sought. No failure or delay by either Party to exercise any right or enforce any obligation shall impair or be construed as a waiver or on-going waiver of that or any or other right or power, unless made in writing and signed by both Parties. If any provision of this Agreement is held to be illegal, invalid, or unenforceable, the remaining provision of this Agreement shall be unimpaired and remain in full force and effect.
Governing Law. This Agreement and all disputes, claims, actions, suits or other proceedings arising hereunder shall be governed by, and construed in accordance with, the substantive law of the State of California applicable to contracts and negligence wholly made and to be performed within the State of California without regard to conflict of laws principals.
4. Consent to Engage in Consultation I understand and acknowledge to receive education and/or consulting and/or health/life coaching either on behalf of myself or as representative. In addition, I understand and acknowledge all of the following:
A. Required disclosures.
Cathay Psychological Institute and its employees, agents, independent contractors, or representatives (collectively “Consultant” or “Counselor” or “Life Coach”) are made up of counselors under supervision by licensed psychologists, counselors or healthcare provider professionals. If a Consultant or Life Coach of Cathay Psychological Institute is a licensed physician, psychologist, or clinician he or she is not acting within his or her scope as a licensed physician, psychologist, or clinician and is acting in his or her limited role as a non-licensed person consulting or coaching. The services offered by Consultant are alternative or complementary to healing arts services in your state. The services that Consultant offers are not licensed by your state or any other state.
Nature of Services: The nature of the services Consultant will be providing are as follows (“Services”):
· Providing me with information as requested to aid in mental health and psychological decision making (Consultant cannot diagnose or provide medical advice);
· Helping me understand both the potential advantages and disadvantages of choices;
· Teaching and educating me about mental health and psychological issues;
· Teaching and educating me about coping strategies to manage mental health and psychological issues;
The nature of the services Consultant will not be providing are as follows:
· Making healthcare choices for me
· Providing Medical, Financial, or Legal advice and/or the practice of medicine;
· Accepting insurance, so all payments are out of pocket;
· Writing prescriptions; and
· Guaranteeing any outcomes or results.
B. No Guarantee: I recognize that Consultant cannot guarantee results or any specific outcomes from our work together. I am solely responsible for any action taken based on my interpretation of any information presented.
C. Right to discontinue services. I understand that Consultant has the right to refuse to continue delivering services at any time for any reason whatsoever and will refund my payment in full for the portion of unused services.
D. My Responsibility for My Self-Care. I understand that I am responsible for my self-care. I agree to communicate critical information as well as my needs, concerns and wants as clearly and promptly as possible. I expect to learn and advocate on my own behalf when possible. I expect to be treated with respect and compassion. I agree to seek medical assistance or any other appropriate physical or mental diagnosis and treatment from a practitioner duly licensed (such as a licensed medical doctor or licensed psychologist) if I find that these distressing aspects create a danger for myself or for others.
E. Expected Benefits. Benefits are variable, unique, and depend completely on the client. Consultant cannot guarantee any benefits or effects but in working with Consultant I could expect to make better informed decisions regarding my mental wellness and that my stress or anxiety about making these decisions might decrease. Healing journeys are extremely variable, unexpected events happen and unforeseen challenges arise all the time and Consultant cannot guarantee any results.
F. Counterparts and Interpretation. This Consent form is to be executed electronically. This shall constitute one single agreement of consent.
G. Governing Law. This Consent form and all disputes, claims, actions, suits or other proceedings arising hereunder shall be governed by, and construed in accordance with, the substantive law of the State of California applicable to contracts and negligence wholly made and to be performed within the State of California without regard to conflict of laws principals.
H. Arbitration. Any dispute, claim, or controversy arising out of or relating to this Agreement or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this agreement to arbitrate, shall be determined by arbitration in Sacramento, California, before one (1) arbitrator. The arbitration shall be administered by AHLA Alternative Dispute Resolution Service Rules of Procedure for Arbitration, in Sacramento, California. Judgment on the award may be entered in any court having jurisdiction. This provision shall not preclude either party from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. The arbitrator may, in the award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator. Each party has read and understood this Section (Arbitration) and understands that it thereby agrees to submit any claims arising out of this Agreement to binding arbitration, and that this dispute resolution provision constitutes a waiver of the Party’s right to a jury trial. HOWEVER, prior to either party initiating Arbitration of any dispute, the parties agree to attempt mediation of the dispute with a mutually agreeable trained mediator in Sacramento, California. “Trained mediator” means a professional with actual training and experience in the field of Mediation and/or dispute resolution. BY SIGNING YOUR NAME TO THIS AGREEMENT, YOU AGREE TO SUBMIT ANY CLAIMS ARISING OUT OF, RELATING TO, OR IN CONNECTION WITH THIS AGREEMENT, OR THE INTERPRETATION, VALIDITY, CONSTRUCTION, PERFORMANCE, BREACH, OR TERMINATION THEREOF TO MEDIATION AND ARBITRATION, AND THAT THE DISPUTE RESOLUTION PROVISIONS SET FORTH IN THIS SECTION CONSTITUTE A WAIVER OF THE PARTY’S RIGHT TO A JURY TRIAL.
I. Capacity. I represent and warrant that I am of sound mind and able to understand the nature and consequences of this Consent form at the time the Consent form was signed.
Client Agreement: I have carefully read this form, which is printed in English, and acknowledge that English is a language I read and understand, and that I understand the form. I do not feel rushed or impaired, nor am I under the influence of a sedative or sleep-inducing medication. I accept and agree to all of the terms above.
I am free to refuse or withdraw my consent and to discontinue participation in any treatment, service, or research at any time without fear of reprisal against or prejudice to me. No representations, statements, or inducements, oral or written, apart from the foregoing written statement, have been made. I may request and receive a copy of this form from Company. If any portion of this form is held invalid, the rest of the document will continue in full force and effect.
I am responsible for my own health care decision-making by obtaining any necessary consultations with appropriately licensed health care professionals.