Couples Coaching

Please complete this form before your couples coaching call. Coaching is not the same as psychological services — as your coach, Dr. Dalgleish cannot provide assessment, diagnosis, or psychotherapy. Each partner completes their own form.

Your Privacy

How it's protected: your answers are encrypted in transit and sent through a secure, healthcare-grade service to Dr. Dalgleish's access-controlled inbox. They are not stored on this website.
Who sees it: only Dr. Dalgleish and, where necessary, authorized staff bound by confidentiality.
Your rights: you may ask to see or correct your information at any time.

About You & Your Goals

First & Last Name *

Email *

Please provide your location (State/Province, Country) *

Describe the problem as specifically as you can. If you have a specific question, you can ask it here and we'll get clear on the call. *

According to a loved one (your partner, family member), what would they say is the problem or something that needs to change?

Goals: If something were to change, what would it be? *

Goals: What are your long-term goals (over 5 years)? What are your short-term goals?

What is important to you right now?

If that change you identified above took place, how would your relationship(s) feel? *

What things do you do to cope with the problem stated above, or to deal with stress in general?

Take a moment to dig into your relationships. What patterns do you see unfolding?

Have you ever been to therapy before or done any other coaching?

Has a medical professional given you a mental health diagnosis before?

Yes No

Please indicate your profession/occupation(s)

How do you feel about directive advice?

Coaching Consent

Please take a moment to review.

You are consenting to receive coaching services. Coaching is aimed at identifying and reaching identified goals, changing behaviors that are not working for you, and giving you specific action-oriented directions related to how you might reach your goals.

It is important for you to note that as a coach, I am NOT providing you with psychological services including psychological assessment or psychological treatment. In this capacity as a coach, I will not be held liable for discrepancies between coaching and psychotherapy.

Online coaching is NOT INTENDED TO, NOR DOES IT PROVIDE PSYCHOTHERAPY, MEDICAL ADVICE, DIAGNOSIS, OR MEDICAL TREATMENT. Coaching is not a licensed or regulated service. This service is not intended to address psychological issues such as depression and anxiety. For these specific issues, should I see that services are needed from a physician or licensed mental health professional in your area, I will make this referral.

By accepting this agreement, you are agreeing that you understand the difference in these two functions and that you will get appropriate help for your mental health, should this be necessary.

Confidentiality

Confidentiality is important to me. At no point is your personal information shared without your written, informed consent. However, exceptions to confidentiality include the legal obligation to:

Inform an appropriate resource person of a client's intention to end his/her life.
Inform a potential victim and/or police of physical violence or a client's intention to inflict harm to another person.
Inform the appropriate authorities (e.g. Children's Aid Society) if a client discloses ongoing physical, emotional and/or sexual abuse or neglect of a child under the age of 16.
Inform the appropriate authorities if there are concerns that a resident in a long-term care facility or retirement home has experienced harm or is at risk of harm.
Inform a healthcare provider's professional association if a client discloses sexual abuse of the client (disclosure of the client's identity not necessary).

Privacy Policy: Consent for Personal Information

I adhere to the Federal Privacy legislation, which means the collection, use and disclosure of personal information, protection of that information, and your right to review personal information is within compliance to this privacy policy.

As we are using the Secure Video platform, please note that this platform complies with HIPAA requirements to ensure your privacy.

A note about email communications: due to the nature of email, while my account is only accessed by me, email services cannot guarantee complete privacy. As such, I do not communicate about coaching-specific issues through email.

Fee for Coaching & Cancellation Policy

The fee for a coaching appointment is $500 USD. Meetings are 55 minutes in length and the remaining 5 minutes are used for important documentation and file management. Payment for services can be made through our secure payment portal or by e-transfer to help.beconnected@gmail.com.

If you must reschedule or cancel an appointment, please inform me with at least 24 hours notice. This allows me to offer the appointment to another client. If an appointment is missed or given less than 24 hours notice, the full fee for the session will be applied.

Contact Information

I can be reached at help.beconnected@gmail.com. Messages are responded to during regular office hours, Eastern Standard Time.

Signature

By signing below, I confirm that I have read and agree to the Coaching Consent above.

Draw Type

Date *