Informed Consent/Terms & Conditions

The following informed consent is provided to acquaint you with the policies and procedures of our TAKE 2 Counseling & Coaching practice. The Terms of Service (“Terms”) contained herein govern the Client’s relationship with TAKE 2 Counseling & Coaching. Please read these Terms of Service carefully before using the Service. Access to, and use of the Service, is based on the Client’s acceptance of, and compliance with, these Terms. These Terms apply to all visitors, users and others who access or use the Service. By accessing or using the Service you agree to be bound by these Terms and accept all legal consequences.

Your Rights as a Client:

You have the right to ask questions about the procedures used during therapy.

You have the right to cancel TAKE 2 Counseling & Coaching services without any additional financial obligations. We can provide additional resources at your request.

Confidentiality:

Within certain limits, your information will be kept strictly confidential and will not be revealed to any other person or agency without your informed written consent.

There are certain situations where your clinician is required by law to reveal information obtained during therapy to other persons or agencies without your permission. These situations include:

· If you threaten bodily harm or death to another person, your clinician is required by law to inform the intended victim and appropriate law enforcement agencies.

· If you threaten bodily harm or death to yourself, your clinician will inform the appropriate law enforcement agencies and others (such as spouse, friend or an inpatient psychiatric institution) who can aid in prohibiting you from carrying out your threats.

· If you reveal information related to the abuse or neglect of a child, dependent adult or elderly person, your clinician is required by law to report this to the appropriate authorities.

· I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist.

Confidentiality for Couples/Families

If clients enter into family therapy or couples therapy (relational therapy), confidentiality will be kept within the family. The relationship unit is considered the client. Your clinician is unable to keep secrets that may be harmful to the relationship as this may warrant immediate termination. If an individual needs to work through something prior to sharing the information, the clinician will help the client move to a place where this can be shared. If the person is unable to disclose the information, termination may be necessary and resources can be provided. During the course of our work together, a smaller portion of the relational unit can be seen for one or more sessions individually. These sessions can be seen as part of the work we are doing together. If you as an individual are involved in any such sessions, please understand that any information disclosed in these sessions may need to be shared with the entire relational unit.

Clients participating in couples/marriage therapy agree they will not seek to subpoena material for litigation against each other at any time.

If you are the guardian of a minor/ are a minor, please read the following:

I have been informed of the limitations of confidentiality in terms of the treatment of the minor. I understand that special care and sensitivity may be required in releasing information to me about certain topics such as substance use and sexual activity. I understand that if my child is in danger of hurting himself or herself, my clinician at TAKE 2 Counseling & Coaching, LLC, will notify me immediately.

Therapy Services and Fees:

Counseling with Licensed Clinician:

· Fee for initial assessment: $175

· Fee for a 45-60 minute individual session: $125

· Fee for a Couple’s and Family Session: $175

*Please note: Insurance companies will not reimburse for services if you do not have out of network mental health benefits.

Payment in full is due at the time of the visit through cash, credit or check. There will be an additional $25 fee for a bounced check.

Receipts will be provided upon request and can be submitted to insurance companies for reimbursement (for counseling sessions) if you have out-of-network benefits.

A 24-hour notice is required for cancellation of a scheduled session. If I do not meet this requirement, I agree to pay the full session fee. I understand that this is solely my responsibility and I will not be able to submit this fee to my insurance company for reimbursement.

I understand the practitioner at TAKE 2 Counseling & Coaching, LLC. has the right to seek legal recourse to recoup any unpaid balance. In pursuing these measures, the therapist will only disclose biographical information and the amount owed, in order to ensure confidentiality.

My practitioner at TAKE 2 Counseling & Coaching, LLC. can be reached at (732) 365-3933. Feel free to leave a message with your name and call back number. Messages will be checked and returned as soon as possible.

I understand that the therapist is not providing emergency services and I have been informed of where to call in an emergency or during the evening or weekend hours. If you are in need of immediate care or there is an emergency, you must call 911 or go to your nearest hospital.

If information is to be released to a third party, each member who participated in treatment will be required to consent to and sign a release of information.

Consent for Treatment

While I expect benefits from this treatment I fully understand and accept that because of factors beyond our control, such benefits and desired outcomes cannot be guaranteed.

I am aware that the psychotherapeutic process can bring up uncomfortable feelings and reactions such as anxiety, sadness, and anger. I understand that this is a normal response to working through unresolved life experiences and that these reactions will be worked on between my practitioner and I.

Terms & Conditions

We reserve the right to modify, alter or update this Agreement at any time in our sole discretion by posting any such modified, altered or updated version of this Agreement on the Services.

All such modifications, alterations and updates will become effective immediately upon posting. We encourage you to check this page each time you visit the Services. Except as otherwise expressly stated by us, any use of the Services is subject to the version of this Agreement in effect at the time of use. Your continued use of the Services after any modifications, alterations or updates are made constitutes your acknowledgement of such changes. When using the Services, you agree that you are subject to any additional posted guidelines, rules, terms and conditions applicable to the Services, which are hereby incorporated by reference into this Agreement.

Trademarks

The Take 2 Counseling & Coaching name, logo and all related names, are trademarks of Take 2 Counseling & Coaching or its licensors. You must not use such marks without the prior written permission of the Organization. All other names, logos, product and service names, designs and slogans on the Services are the trademarks of their respective owners.

Third Party Website and Links

The Services may contain links to third party websites or online resources that are not owned, operated or controlled by us. All such links are provided solely as a convenience to you. We do not control, recommend or endorse and are not responsible for these websites or their content, products, services or privacy policies or practices. In no event shall we be liable, directly or indirectly, to you or any other person or entity for any loss or damage arising from or occasioned by the creation or use of the third party websites or the information or material accessed through these third party websites. If you decide to access any other website linked to or from the Services, you do so entirely at your own risk and subject to the terms and conditions of use for such third party websites.

Indemnification

By using the Services, you agree to defend, indemnify, and hold the Organization and its affiliates and their respective officers, directors, employees, contractors and suppliers harmless from any and all claims, demands, liabilities, damages, losses, costs, and expenses (including without limitation, attorneys’ fees and expenses, including any incurred in enforcement of this indemnity) arising in any way from or in connection with your use of the Site or Services or any goods and services available on or through the Site or Services, or any violation by you of this Agreement, our Privacy Notice or any other policy posted on the Services applicable to your use of the Services. We reserve the right to assume the exclusive defense and control of any matter otherwise subject to indemnification by you, in which event you agree to assist and cooperate with us in asserting any available defenses.

Governing Law

The Services are controlled, operated, and hosted from the United States, and are not intended to subject the Organization to the laws or jurisdiction of any state, country or territory other than that of the United States. We do not represent or warrant the Services, the content on the Services, or any part thereof is appropriate or available for use in other locations or in any particular jurisdiction other than the United States. Persons who choose to access the Services from other locations or jurisdictions do so on their own initiative and at their own risk, and are responsible for compliance with local laws, rules and regulations, if and to the extent local laws are applicable. We may limit the availability of the Site or Services, in whole or in part, to any person, geographic area or jurisdiction we choose, at any time and in our sole discretion.

You agree that the laws of the State of New Jersey, excluding its conflict of laws rules, and this Agreement, our Privacy Notice and any other policies posted on the Services applicable to your use of the Services shall govern your use of the Services. You expressly agree that exclusive jurisdiction for any claim or dispute with us or relating in any way to your use of the Services resides in the courts of New Jersey, and you further agree and expressly consent to the exercise of personal jurisdiction in the courts of New Jersey, in connection with any such dispute and including any claim involving the Organization and its affiliates and their respective employees, contractors, officers, directors, and suppliers.

This Agreement is the entire agreement between you and the Organization with respect to the Site and Services, and supersedes all prior or contemporaneous communications and proposals (whether oral, written or electronic) between you and the Organization with respect to those matters. No agency, partnership, joint venture, or employment relationship is created as a result of this Agreement, and neither party has any authority of any kind to bind the other in any respect. If any of the provisions, or portions thereof, of this Agreement is found to be invalid under any applicable statute or rule of law, the remainder of this Agreement shall remain in full force and effect and such provision or portion thereof shall be deemed omitted.

Arbitration

Any and all controversies, disputes, demands, counts, claims, or causes of action (including the interpretation and scope of this clause, and the arbitrability of the controversy, dispute, demand, count, claim, or cause of action) between you and the Organization and their successors or assigns shall exclusively be settled through binding and confidential arbitration.

Arbitration shall be subject to the Federal Arbitration Act and not any state arbitration law. Unless otherwise agreed upon by the parties in writing, the arbitration will be conducted before one arbitrator and will be governed by the American Arbitration Association’s (“AAA”) Commercial Arbitration Rules and, if the arbitrator deems them applicable, the Supplementary Procedures for Consumer Related Disputes (collectively, the “Rules and Procedures”).

To the fullest extent permitted by applicable law, you and the Organization must abide by the following rules: (1) ANY CLAIMS BROUGHT BY YOU OR THE ORGANIZATION MUST BE BROUGHT IN THE PARTY’S INDIVIDUAL CAPACITY, AND NOT AS A PLAINTIFF OR CLASS MEMBER IN ANY PURPORTED CLASS OR REPRESENTATIVE PROCEEDING; (2) THE ARBITRATOR MAY NOT CONSOLIDATE MORE THAN ONE PERSON’S CLAIMS, MAY NOT OTHERWISE PRESIDE OVER ANY FORM OF A REPRESENTATIVE OR CLASS PROCEEDING, AND MAY NOT AWARD CLASS-WIDE RELIEF; (3) the arbitration shall be confidential, and neither you nor the Organization may disclose the existence, content or results of any arbitration, except as may be required by law or for purposes of enforcement of the arbitration award; (4) the arbitrator may award any individual relief or individual remedies that are permitted by applicable law; and (5) each side pays its own attorneys’ fees and expenses unless there is a statutory provision that requires the prevailing party to be paid its fees and litigation expenses, and, in such instance, the fees and costs awarded shall be determined by the applicable law.

DISCLAIMER: THIS WEBSITE DOES NOT PROVIDE MEDICAL ADVICE

IMPORTANT NOTE REGARDING HEALTH-RELATED INFORMATION: YOUR USE OF THE SERVICES AND ANY INFORMATION PROVIDED ON OR IN CONNECTION WITH THE SERVICES IS AT YOUR OWN RISK. THE SERVICES MAY INCLUDE CERTAIN INFORMATION REGARDING HEALTH-RELATED ISSUES. SUCH INFORMATION (A) IS NOT INTENDED AS A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE, DIAGNOSIS OR TREATMENT, (B) SHOULD NOT BE CONSTRUED AS THE PROVISION OF ADVICE OR RECOMMENDATIONS, AND (C) SHOULD NOT BE RELIED UPON AS THE BASIS FOR ANY DECISION OR ACTION, INCLUDING WITHOUT LIMITATION THE DIAGNOSIS OR TREATMENT OF ANY HEALTH PROBLEM. THE ORGANIZATION IS NOT RESPONSIBLE FOR THE ACCURACY OR RELIABILITY OF ANY SUCH INFORMATION. SUCH INFORMATION IS NOT EXHAUSTIVE AND SHOULD NOT BE CONSIDERED COMPLETE OR UP-TO-DATE. IT IS YOUR RESPONSIBILITY TO EVALUATE THE ACCURACY, COMPLETENESS OR USEFULNESS OF ANY INFORMATION AVAILABLE THROUGH THE SERVICES. THE RELATIONSHIP BETWEEN YOU AND THE ORGANIZATION IS NOT A PHYSICIAN-PATIENT OR SIMILAR RELATIONSHIP; ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH PROVIDER WITH ANY QUESTIONS YOU MAY HAVE REGARDING A MEDICAL CONDITION, AND NEVER DISREGARD PROFESSIONAL MEDICAL ADVICE OR DELAY IN SEEKING IT BECAUSE OF SOMETHING YOU HAVE READ OR HEARD ON THE SERVICES. THE ORGANIZATION DOES NOT RECOMMEND OR ENDORSE ANY SPECIFIC TESTS, PHYSICIANS, PRODUCTS, PROCEDURES, OPINIONS, OR OTHER INFORMATION THAT MAY BE MENTIONED ON THE SERVICES. RELIANCE ON ANY INFORMATION PROVIDED BY THE ORGANIZATION, THE ORGANIZATION’S EMPLOYEES, INDIVIDUALS PROVIDING INFORMATION IN CONNECTION WITH THE SERVICES AT THE INVITATION OF THE ORGANIZATION, OTHER VISITORS OR USERS OF THE SERVICES AND/OR ANY OTHER THIRD PARTY IS SOLELY AT YOUR OWN RISK.

Limitation of Liability

TO THE EXTENT PERMISSIBLE BY APPLICABLE LAW, IN NO EVENT SHALL THE ORGANIZATION AND ITS AFFILIATES OR THEIR RESPECTIVE EMPLOYEES, OFFICERS, DIRECTORS, SHAREHOLDERS, AFFILIATES, AGENTS, REPRESENTATIVES, LICENSORS, SUPPLIERS AND SERVICE PROVIDERS BE LIABLE TO ANY PARTY FOR DAMAGES OF ANY KIND, UNDER ANY LEGAL THEORY, ARISING OUT OF OR RELATED TO THE AVAILABILITY, USE, RELIANCE ON, OR INABILITY TO USE THE SITE, SERVICES, OR ANY CONTENT OR OTHER MATERIALS ON, ACCESSED THROUGH OR DOWNLOADED FROM THE SITE OR SERVICES, INCLUDING ANY DIRECT, INDIRECT, SPECIAL, EXEMPLARY, INCIDENTAL, CONSEQUENTIAL OR PUNITIVE DAMAGES, INCLUDING BUT NOT LIMITED TO, PERSONAL INJURY, PAIN AND SUFFERING, EMOTIONAL DISTRESS, LOSS OF REVENUE, LOSS OF PROFITS, LOSS OF BUSINESS OR ANTICIPATED SAVINGS, LOSS OF USE, LOSS OF GOODWILL, LOSS OF DATA, AND WHETHER CAUSED BY TORT (INCLUDING NEGLIGENCE), BREACH OF CONTRACT OR OTHERWISE, EVEN IF FORESEEABLE. YOUR SOLE AND EXCLUSIVE REMEDY FOR ANY OF THE ABOVE CLAIMS OR FOR DISPUTES AGAINST US IS TO DISCONTINUE YOUR USE OF THE SITE AND/OR SERVICES. NOTHING IN THESE TERMS OF USE SHALL BE DEEMED TO EXCLUDE OR LIMIT YOUR LIABILITY IN RESPECT OF ANY INDEMNITY GIVEN BY YOU UNDER THESE TERMS OF USE.

THE FOREGOING DOES NOT AFFECT ANY LIABILITY WHICH CANNOT BE EXCLUDED OR LIMITED UNDER APPLICABLE LAW.

Termination

The Organization, in its sole discretion, may terminate your access to or use of the Services, at any time and for any reason, including if the Organization believes that you have violated or acted inconsistently with the letter or spirit of this Agreement. Upon any such termination, your right to use the Services will immediately cease. You agree that any termination of your access to or use of the Services may be effected without prior notice, and that the Organization may immediately deactivate or delete your password and user name, and all related information and files associated with it, and/or bar any further access to such information or files. You agree that the Organization and its affiliates shall not be liable to you or any third party for any termination of your access to the Services or to any such information or files, and shall not be required to make such information or files available to you after any such termination.

If you have any questions regarding this Agreement, please direct such questions to Jelysa Deserio at Info@Take2counselingNJ.com