I welcome you to the work we are going to do together. This document constitutes a contract between us and you should read it carefully and raise any questions and concerns that you have before you sign it.

 The services to be provided by Darla Sedlacek are therapy, therapy plus movement, and sport performance therapy, or telepsychology as designed jointly with the client.

 The fee for the initial assessment is $170, ongoing sessions will also be charged at the rate of $170 per 45-50 minute sessions unless there is an agreement for an alternative fee schedule. Professional time spent outside of therapy sessions, including, but not limited to, between-session phone calls or email exchanges, report writing, and reading or reviewing documents, will be billed at $45 per 15 minute increments. Fees for sessions must be paid at the time of the session. 

 You are required to give 24 hours notice if you need to cancel or change the time of an appointment. Otherwise, you will be charged for the session in full. Darla Sedlacek agrees that every effort will be made to reschedule sessions which are cancelled in a timely manner.

 Psychotherapy

 I am licensed in Ohio as a Psychologist with training and experience in diagnosing and treating emotional difficulties. Psychotherapy is a health care service and is usually reimbursable through health insurance policies. You may request a receipt to submit to your insurance company to obtain reimbursement for what portion of the fee is covered. Psychotherapy utilizes knowledge of human behavior, motivation and behavioral change, and interactive counseling techniques. 

 The focus of my therapies is development and implementation of strategies to reach client-identified goals, including increased life satisfaction, resolution of difficulties surrounding ongoing conflicts, enhanced sport performance, and coping for difficulties with mood, anxiety, trauma, and body issues.  We may address specific personal projects, life balance, job performance and satisfaction, or general conditions in your life, business, or profession. We may utilize personal strategic planning, values clarification, brainstorming, motivational counseling, and other counseling techniques. We may also utilize movement practices such as fitness or yoga training to enhance the therapeutic work.

 Most research on therapy outcomes indicates that the quality of the relationship is most closely correlated with therapeutic progress. This is why it’s important to work with a therapist that you feel is a good “fit” for you. Therapy clients are often emotionally vulnerable. This vulnerability is increased by the expectation that they will discuss very intimate personal data and expose feelings about themselves about which they are understandably sensitive. These factors give psychotherapists greatly disproportionate power that creates a responsibility to protect the safety of their clients and to “above all else, do no harm.” 

 You, the client, set the agenda and the success of our work together depends on your willingness to take risks and try new approaches to your concerns. You can count on me to be honest and straightforward, asking questions and using sometimes challenging techniques to assist you to move forward. I will hold space for you to feel and think in a way that understanding, insight, and creative problem solving may be achieved. You are expected to evaluate progress and when therapy feels like it is not working as you wish, you should immediately inform me so we can both take steps to correct the problem.

 It is also important to understand that therapy involves a professional relationship. While it may often feel like a close personal relationship, it is not one that can extend beyond professional boundaries both during and after our work together.

  Confidentiality

 I am ethically and legally bound to protect the confidentiality of our communications.  I will only release information about our work to others with your written permission or in response to a court order.  There are some situations in which I am legally obligated to breach confidentiality in order to protect you or others from harm. If I have information that indicates that a child or elderly or disabled person is being abused, I must report that to the appropriate state agency. If a client is an imminent risk to him/herself or makes threats of imminent violence against another, I am required to take protective actions.  These situations are quite rare in my practice. If such a situation occurs in our relationship, I will make every effort to discuss it with you before taking any action.

 As you are no doubt aware, it is impossible to protect the confidentiality of information that is transmitted electronically. This is particularly true of e-mail and information stored on computers that are connected to the internet, which do not utilize encryption and other forms of security protection.

 Telepsychology

 As a client receiving psychological services through telepsychology methods, understand:

 This service is provided by technology (including but not limited to video, phone, text, and email) and may not involve direct, face to face, communication. There are benefits and limitations to this service. You will need access to, and familiarity with, the appropriate technology to participate in the service provided. Exchange of information will not be direct and any paperwork exchanged will likely be exchanged through electronic means or through postal delivery.

 If a need for direct, face to face services arises, it is your responsibility to contact providers in your area or to contact this office for a face to face appointment. You understand that an opening may not be immediately available.

 You may decline any telepsychology services at any time without jeopardizing access to future care, services, and benefits.

 These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over the internet that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. We will regularly reassess the appropriateness of continuing to deliver services through the use of technology.

 Your psychologist may utilize alternative means of communication (if disruption in service, emergency) and will respond to communications and routine messages within 24 hours. 

 It is your responsibility to maintain privacy on your (client) end of communication. Insurance companies, those authorized by the you, the client, and those permitted by law may also have access to records or communications.

 You will take precautions to ensure that your communications are directed only to your psychologist or other individuals.

 The laws and professional standards that apply to in-person psychological services also apply to telepsychology services.

 This document does not replace other agreements, contracts, or documentation of informed consent.

Movement Therapies

I represent and warrant that I am in good physical health and do not suffer from any medical condition which would limit my participation in the training sessions offered by Darla Sedlacek, including psychotherapy, yoga, fitness training, movement based classes, self defense seminars.  I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any of the movement based programs. I understand the risks associated with the activities offered, I agree to follow all instructions so that I may safely participate in training sessions, workshops, or other activities.

 I hereby WAIVE AND RELEASE Ride the Waves, Inc., Darla Sedlacek its owner, officers, employees, and instructors from any claim, demand, cause of action of any kind resulting from or related to my participation in the programs offered. If taking part in psychotherapy, yoga, fitness training, self defense workshops, or other activities, I understand and acknowledge that I am fully responsible for any and all risks, injuries, or damages, known or unknown, which might occur as a result of my participation in the training sessions, workshops, or other activities. I understand that the physical and mental techniques I practice in therapy, movement therapy with yoga, fitness practices, or self defense training may result in discomfort, stress, or physical injury.  IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same.