Client Intake Form

Emergency Contact: I acknowledge that the services I receive from Allyson Blythe, LCSW are confidential. I also understand that should Allyson Blythe, LCSW assess that I present a risk to myself or others, or that there is a potential risk to me, Allyson Blythe, LCSW is under obligation to report such risks. In case of an emergency, I release Allyson Blythe, LCSW to contact:

1. Consent to Treatment:
I understand that treatment is a cooperative effort that involves open and honest communication between myself and my therapist. Because difficult feelings and issues may need to be experienced and addressed, I understand there are certain risks associated with psychotherapy that include, but are not limited to: worsening of mood, behavior, and/or functioning. I acknowledge that the benefits of treatment may not be immediately realized and understand that no guarantee or assurance is made as to the results that may be obtained. I hereby consent to treatment.

2. Fee-For-Service:
I understand that I am fully responsible for payment of services and products provided. Payment is due at the time of service. I understand that I am responsible for payment for all services, missed, or late-cancelled appointments.

3. Release of Information / Assignment of Insurance Benefits:
I understand that in the course of my treatment, it may be necessary for Allyson Blythe, LCSW to share my mental health information with other specialists, physicians, and/or health care agencies. Mental health information may also be shared with my insurance carrier should I decide to submit claims to my insurance company.

4. Emergency Contacts:
I acknowledge that the services I receive from Allyson Blythe, LCSW are confidential. I
also understand that should Allyson Blythe, LCSW assess that I present a risk to myself
or others, or that there is a potential risk to me, Allyson Blythe, LCSW is under obligation to report such risks. In case of an emergency, I release Allyson Blythe, LCSW to contact:

Purpose of Coaching:

Life coaching is a collaborative, forward-focused process designed to support your growth, awareness, and intentional change. This is a space where we explore patterns, beliefs, behaviors, relationships, and decision-making in a grounded, honest, and empowering way.

Coaching is goal-focused and is not therapy. It does not diagnose or treat mental health conditions. Although I am a Licensed Clinical Social Worker (LCSW), in this relationship I am serving solely in the role of a Life Coach. Coaching services are not clinical services and do not constitute psychotherapy or mental health treatment.

Nature of Services:

This is a partnership. I am not here to fix, rescue, or chase. I stand with you, reflect truth, and support you in reconnecting with your own clarity and strength.

You are responsible for your choices, actions, and results.

Not a Substitute for Therapy or Medical Care:

Coaching is not a substitute for psychotherapy, mental health treatment, or medical care. If you are in crisis or need clinical support, you agree to seek appropriate licensed care. If you are experiencing severe emotional distress, thoughts of harm to yourself or others, or are in crisis, you agree to seek appropriate professional support immediately by calling 911, going to your nearest emergency room, or contacting the Suicide & Crisis Lifeline at 988.

Confidentiality:

Your privacy is important and will be respected. Information shared during coaching sessions will be held with care and discretion. Exceptions to confidentiality may occur if there is a serious risk of harm to yourself or others, or in cases of suspected abuse or neglect of a minor, elder, or vulnerable adult, or when otherwise required by law.

Telehealth Services:

Sessions may take place via phone or video. By participating in telehealth services, you acknowledge that:

- You are responsible for ensuring a private and appropriate environment

- Technology carries inherent risks, including interruptions or breaches of confidentiality

- While reasonable efforts will be made to protect your information, confidentiality cannot be guaranteed over electronic communication

- Allyson Blythe is not responsible for technical difficulties that may impact sessions

Communication Between Sessions:

Email at allysonblythe@live.com may be used for scheduling, appointment changes or cancelations, brief check-ins, or updates. Coaching work and extended processing will occur during scheduled sessions.

Please note: The contact number is a landline; text messaging is not available.

Fees & Cancellations:

Session Fees are $150 for 50 minutes.

A $5.00 processing fee applies to credit card payments.

Payment is due at the time of service.

A minimum of 24-hour notice is required for cancellations. Sessions cancelled with less than 24-hour notice or missed sessions will be charged the full session fee.

Client Responsibility:

Growth requires honesty, willingness, and action. Results are not guaranteed and depend on your level of engagement and commitment.