Student Contract
Welcome! We are excited to welcome you to our Champion Family + learning community. Here are some thoughts about how we can best honor each other and the coaching process. If you have questions or concerns, I am happy to discuss them at any time. Take control of your learning – ask early, ask often!
My Commitment to You
I will always have your best interests at heart, and I will always be honest with you.
I will always keep you accountable to your highest goals for yourself, and to the action items you agree to do.
I will always help you problem solve from the point of view that you are a powerful advocate in your own life (and not a victim to teachers, school systems, parents, etc.)
I will take session notes which parents will automatically have access to. If you request that specific information be kept confidential, I will do so unless I believe your life or well-being may be at risk.
Sessions may occasionally be recorded for the benefit of analysis of our work. These recordings will always remain private and will never be shared without written permission from you.
Your Commitment to Me
You will do your best to complete the work you promise to do.
You will communicate frequently about what is and is not working for you, so that I can provide the best possible service to you.
If you know that you will not be able to make a scheduled session, you will give me at least a 72 hour notice.
You will be on time for our sessions.
You will bring your full focus to our sessions, including silencing & putting away all devices and distracting browser tabs and computer applications.
When you sometimes make mistakes, you will focus on the learning and growth.
You will learn how to video chat on a virtual learning platform, if you don’t already know how to use these platforms.
You will ensure you can regularly access our shared Google Doc. This will be our virtual “home base” for our sessions together, serving as a primary point of interaction. For academic coaching sessions, it will also serve as a report card that will be included in your PULSE portfolio.
Coach/Counselor Name:
Coach/Counselor Signature: Date:
Student Name:
Student Signature: Date:
CONFIDENTIALITY PROMISE
Champion acknowledges that in the course of academic and life coaching and counseling, sensitive personal information may be shared. No contents of any coaching and counseling session - verbal or written - will be shared with any other party without consent of the student and/or parents.
SCHEDULE OF RATES*
*Rates and terms are subject to change.
Coaching and Counseling Sessions:
Champion coaching and counseling sessions are typically either 60- or 90-minutes in duration. Sessions can be conducted in person, or over a number of internet communication platforms such as Skype, Facetime, or Zoom.
Email, Telephone Consultation & Written Reports:
Please note that hourly fees as outlined above will be applicable for:
• Preparation of reports or other written documentation requested
• Telephone consultations with other professionals as agreed with you (Email and telephone consultation is available for brief feedback and queries. Should a more in-depth conversation be required, a coaching session will be requested.)
PAYMENT TERMS
Payment is due at the completion of each session for drop-in sessions. Regularly scheduled clients will be billed at the end of each month. Please process payment within 7 days of the invoice date. Late fees accrue at a rate of 5% for every 7 day period past the due date. Late fee amounts are billed on a monthly basis.
CANCELLATION POLICY
Champion maintains a full 72-hour cancellation policy. If you are unable to attend a scheduled appointment, we ask that you provide notice at least 72-hours in advance to enable us to reschedule for another student. If scheduled sessions are cancelled less than 72-hours in advance, full payment will remain due. No-Refund/Transfer/Postponement for Champion Academy seminar and workshop registrations. Once paid, all registration fees are non-refundable.
If scheduled sessions are canceled less than 72 hours in advance, full payment will remain due.
Student Name: _________________________ DOB (Age): _____ School: _____________________
Home Address: _________________________________________________________________
Parent/Guardian Name: ___________________________________________________________
Parent/Guardian Signature: ___________________________________ Date: ________________
How did you hear about us?
"Success is not final, failure is not fatal: it is the courage to continue that counts."
- Winston Churchill
Psychological& Neurodevelopmental Evaluation Consent
Your Rights and Our Policies
Please read and sign below indicating you fully understand the following information
What to Expect
The purpose of meeting with a Champion educational psychologist is to get help with issues in your life that are keeping you from being personally successful. You may be here because you want to explore these issues, or you may be here because your parents /school have suggested it. When we meet, we will discuss the challenges that are concerning you. At Champion we will ask questions, listen to you, and from time to time conduct assessments that will help guide us to a plan for improving your situation. It is important that you feel comfortable talking with us. Sometimes our conversations will include things you don’t want your parents or guardians to know about. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their psychologist. Privacy, also called confidentiality, is an important and necessary part of the assessment process.
As a general rule at Champion we will keep the information you share with us in our coaching, counseling, and assessment session(s) confidential, unless we have your written consent to disclose certain information There are however, exceptions to this rule that are important for you to understand before you share personal information with us in a session. In some situations we are required by the guidelines of the psychology profession (and sometimes the law) to disclose information whether or not we have your permission. We have listed some of these situations below.
Confidentiality cannot be maintained when
• You tell us you plan to cause serious harm to yourself or another person, and we believe you have the intent and ability to carry out this threat in the near future. We must take steps to inform a parent or guardian of what you have told us and how serious we believe this threat to be. We must make sure that you are protected from harming yourself or others.
• You tell us you are being abused physically, sexually or emotionally, or that you have been abused in the past. In this situation we are required by law to consult/ report the abuse to the appropriate agencies.
• You are involved in a court case and a request is made for information about your assessments. If this happens we will not disclose information without your written agreement unless the court requires us to do so. We will do all we can within the law to protect your confidentiality, and if we are required to disclose information to the court we will inform you that this is happening.
Communicating with your parent(s) or guardian(s)
Except for situations such as those mentioned above we will not tell your parent or guardian specific things you share with us in our private assessment sessions. If any risk-taking behavior presents as a serious threat then we will need to use our professional judgment to decide whether you are in serious and immediate danger of being harmed. If we feel that you are in such danger, we will communicate this information to your parent or guardian.
Even if we have agreed to keep information confidential – to not tell your parent or guardian – we may believe that it is important for them to know what is going on in your life. In these situations we will encourage you to tell your parent/guardian and will help you find the best way to tell them. Also, when meeting with your parents we may sometimes describe problems in general terms, without using specifics, in order to help them know how to be more helpful to you.
Communicating with other adults
School: We will not share any information with your school unless we have your permission and permission from your parent or guardian. Sometimes we may request to speak to someone at your school to find out how things are going for you. Also, it may be helpful in some situations for us to give suggestions to your teacher(s) or counselor at school. If we want to contact your school, or if someone at your school wants to contact us, we will discuss it with you and ask for your written permission. A very unlikely situation might come up in which we do not have your permission but Champion and a parent or guardian believe that it is important for us to be able to share certain information with someone at your school. In this situation we will use our professional judgment to decide whether to share any information.
Doctors: Sometimes your doctor and Champion may need to work together. For example, if your assessment indicates a need to take medication for any number of reasons, we will get your written permission and permission from your parent/guardian in advance to share relevant information with your doctor. The only time we will share information with your doctor without your permission is if you are doing something that puts you at risk for what could reasonably be deemed serious physical/medical harm.
Client
Signing below indicates that you have reviewed the policies described above and understand the limits to confidentiality. If you have any questions as we progress, you can ask your psychologist at any time.
Client Name:
Client Signature: Date:
Parent/Guardian
Please sign below indicating your agreement to respect your child’s privacy:
• I understand that I will be provided with assessment results and details as they pertain to a psychologicalevaluation.
• I understand that I will be informed about situations that could endanger my child should they arise. I understand this decision to breach confidentiality in such circumstances is subject to the psychologist’s professional judgment and may sometimes be made in confidential consultation with the Champion team.
Student Name: DOB (Age): School:
Parent/Guardian Name:
Parent/Guardian Signature:
How did you hear about us?
Date:
Schedule of Rates & Payment Terms
APPOINTMENTS
Pre-assessment consultations are scheduled through Champion’s administrator (admin@championmylife.com), after which recommendations regarding specific assessments will be made.
Schedule of Rates
School Observations/ Consultations from $572.25 from $525
*Rates and terms are subject to change.
Email, Telephone Consultation & Written Reports:
Email and telephone consultation is available for brief feedback and queries. Should a more in-depth conversation be required, a scheduled session will be requested.
CANCELLATION POLICY
Champion maintains a full 72-hour cancellation policy. If you are unable to attend a scheduled appointment, we ask that you provide notice at least 72 hours in advance to enable us to reschedule with another student/family. If scheduled sessions are cancelled less than 72 hours in advance, full payment will remain due.
PAYMENT TERMS
Payment is due in full for Champion’s Psychological Evaluation at the time of assessment. Late fees accrue at a rate of 5% for every 7 day period past the due date. Late fee amounts are billed on a monthly basis.
