Emergency Contact, Name & Number
Describe your running/fitness goal(s). Include any races or deadlines you are working toward:
List your age, height, and weight:
Describe any injuries or medical issues you have or have had:
Describe your current level of fitness and any exercise activities you currently participate in:
Have you ever included strength or resistance training in your workouts? Do you have other forms of cross training that you enjoy? (e.g. yoga, hiking, biking, weight lifting, etc).
Do you know if you pronate, supinate, or have a neutral gait? If you don’t know, I’d recommend going to your local running shoe store and ask them to assess your gait to recommend shoes.
What do you foresee as possible hurdles to reaching your fitness goal(s)? (e.g. no childcare, limited time, etc)
What assets do you have that will be helpful to you in your training process? (e.g. a can do attitude, raced before)
Are the people in your life supportive of any lifestyle changes you may make in relation to a training program?
I declare that I have read, understand, and agree to the contents of this INFORMED CONSENT for running, walking, and physical activity AGREEMENT in its entirety
I declare that I intend to use some or all of the activities, programs and services offered by Kjersti Nelson, Marathon/Long Distance Running Coach and I understand that each person, (myself included), has a different capacity for participating in such activities, programs and services. I am aware that all activities, services, and programs offered are educational, recreational, or self-directed in nature. I assume full responsibility during and after my participation, for my choices to use or apply, at my own risk, any portion of the information or instruction I receive.
I understand that part of the risk involved in understanding any activity or program is relative to my own state of fitness or health (physical, mental or emotional) and the awareness, care and skill with which I conduct myself in that activity or program. I acknowledge that my choice to participate in any activity, service and program of Kjersti Nelson, LMFT, Marathon/Long Distance Running Coach brings with it the assumption by me of those risks or results stemming from this/these choice(s) and the fitness, health, awareness, care and skill that I possess and use. In addition, I understand that I am free to withdraw from, reduce, or modify my involvement in any program activity and I realize that I should do so upon recognition of any signs of transient lightheadedness, fainting, chest discomfort, leg cramps, nausea, injury, etc.
I understand that running and walking are potentially hazardous activities. I agree not to participate in this running/walking class unless I am medically able. I assume all risks associated with running or walking, but not limited to falls, the condition of the course and road, traffic, contact with other participants, and the effects of weather including heat, humidity, cold and rain. All such risks are known and understood by me. I, the undersigned, hereby waive and release Kjersti Nelson LMFT, Marathon/Long Distance Running Coach and anyone acting on their behalf from any and all claims and liabilities of any kind arising out of my participation in this event. In consideration of being allowed to participate in any way in the Training Program, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that: The risk of injury from the activities involved in this program is significant, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury or death does exist. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of others, and assume full responsibility for my participation; and, I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Coach immediately; and, I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, indemnify, and hold harmless Kjersti Nelson LMFT Running + Therapy, Marathon/Long Distance Running Coach.
I declare that I have read, understand, and agree to the contents of this INFORMED CONSENT for psychotherapy and mental health related activities AGREEMENT in its entirety
This Agreement is intended to provide the Client (herein referred to as “Client”) with important information regarding the practices, polices and procedures of Kjersti Nelson, LMFT 53781 and Run Coach (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
Therapist Background and Qualifications:
Therapist has been a licensed Marriage and Family Therapist since July 2013. Prior to July 2013 most of this Therapist’s experience has been with teens and adults dealing with substance abuse and addiction issues, depression, anxiety, and trauma; children and teens dealing with social skills, family and life transitions, behavior and emotional regulation management, depression, anxiety, and ADHD; positive parenting and improved communication in the midst of conflictual divorce (break ups) and custody plan management. Therapist also has experience, not as a therapist, working with children and adults of all ages with physical and mental disabilities via behavioral techniques and life skills management as prescribed by a licensed behaviorist in the state of Utah along with a treatment team.
Therapist is licensed by the California Board of Behavioral Sciences as a Marriage and Family Therapist, and is an active member of the California Association of Marriage and Family Therapists. Therapist is a graduate of Santa Clara University with a Master of Arts degree in Counseling Psychology. Therapist is also a graduate of Southern Utah University with a Bachelor of Arts degree in Interpersonal Communication and a Bachelor of Arts degree in French. Therapist also holds relevant “Marathon” Run Coaching credentials through the North American Academy for Sports Fitness Professionals (NAASFP). As well is a certified Positive Discipline Parent Educator.
Therapist’s theoretical orientation can be described as:
This therapist uses a “multi-modality” approach to therapy: taking from strength based, psychodynamic, existential, family systems, cognitive/behavioral, mindfulness, somatic, and solution-focused theories.
What “multi-modality” means, is that this therapist borrows from many counseling theories. This therapist will adapt her approach to every individual's unique needs.
In general, Therapist believes each person has enormous capacity to change even in the face of difficult and painful realities. That we make choices everyday that reflect our innate sense of morality but also reflect what and how we assign meaning in our life.
We are learning and adaptive beings. Because of this we are able to look honestly and closely at the intricacies of our thoughts, feelings, and behaviors and make changes that are adaptive and healthy.
We are social beings. Because of this we can find help, motivation, and courage from our communities, families, and friends.
We are relational beings. Because of this we care about how our past, present, and future experiences impact our important relationships. These relationships help to weave together unique life stories that matter especially as we contemplate their negative and positive lasting impacts.
Risks and Benefits of Therapy:
Psychotherapy is a process in which Therapist and Client discuss a myriad of issues, events, experiences and memories for the purpose of creating positive change so Patient can experience his/her life more fully. It provides an opportunity to better, and more deeply understand oneself, as well as, any problems or difficulties Client may be experiencing. Psychotherapy is a joint effort between Client and Therapist. Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors.
Participating in therapy may result in a number of benefits to Client, including, but not limited to, reduced stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviors, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self-confidence. Such benefits may also require substantial effort on the part of Client, including an active participation in the therapeutic process, honesty, and a willingness to change feelings, thoughts and behaviors. There is no guarantee that therapy will yield any or all of the benefits listed above.
Participating in therapy may also involve some discomfort, including remembering and discussing unpleasant events, feelings and experiences. The process may evoke strong feelings of sadness, anger, fear, etc. There may be times in which Therapist will challenge client’s perceptions and assumptions, and offer different perspectives. The issues presented by Client may result in unintended outcomes, including changes in personal relationships. Client should be aware that any decision on the status of his/her personal relationships is the responsibility of Client.
During the therapeutic process, many clients find that they feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times, but may also be slow and frustrating. Client should address any concerns he/she has regarding his/her progress in therapy with Therapist.
Professional consultation is an important component of a healthy psychotherapy practice. As such, Therapist regularly participates in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, Therapist will not reveal any personally identifying information regarding Client.
Records and Record Keeping:
Therapist may take notes during session, and will also produce other notes and records regarding Client’s treatment. These notes constitute Therapist’s clinical and business records, which by law, Therapist is required to maintain. Such records are the sole property of Therapist. Therapist will not alter his/her normal record keeping process at the request of any patient. Should Client request a copy of Therapist’s records, such a request must be made in writing. Therapist reserves the right, under California law, to provide Client with a treatment summary in lieu of actual records. Therapist also reserves the right to refuse to produce a copy of the record under certain circumstances, but may, as requested, provide a copy of the record to another treating health care provider. Therapist will maintain Client’s records for seven years following termination of therapy. However, after seven years, Client’s records will be destroyed in a manner that preserves Client’s confidentiality.
The information disclosed by Client is generally confidential and will not be released to any third party without written authorization from Client, except where required or permitted by law. Exceptions to confidentiality, include, but are not limited to, reporting child, elder and dependent adult abuse, when a client makes a serious threat of violence towards a reasonably identifiable victim, or when a client is dangerous to him/herself or the person or property of another.
In addition, when meeting in outdoor spaces for running+therapy, parenting groups, running+wellness, and any other mental health related activity as provided by Therapist, confidentiality cannot be guaranteed. This therapist will do her best to provide a private context, but in the case that non-participating people are in the vicinity and over-hear any amount of what is shared is out of this therapist’s control. Client agrees to participate knowing that an outdoor context is not always private.
Therapist will not voluntarily participate in any litigation, or custody dispute in which client and another individual, or entity, are parties. Therapist has a policy of not communicating with Client’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in Client’s legal matter. Therapist will generally not provide records or testimony unless compelled to do so. Should Therapist be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving Client, Client agrees to reimburse Therapist for any time spent for preparation, travel, or other time in which Therapist has made him/herself available for such an appearance at Therapist’s usual and customary hourly rate of $150/hr.
The information disclosed by Client, as well as any records created, is subject to the psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between Therapist and client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the client is the holder of the psychotherapist-client privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-client privilege on Client’s behalf until instructed, in writing, to do otherwise by Client or Client’s representative. Client should be aware that he/she might be waiving the psychotherapist-client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorney.
Fee and Fee Arrangements:
The usual and customary fee for service is $150.00 per 50-minute session (the “typical therapy hour”). Sessions longer than 50-minutes are charged for the additional time pro rata. For non-therapy services please visit https://www.kjerstinelson.com/rates for a full list of fees.
Therapist reserves the right to periodically adjust this fee. Client will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. At this time Therapist is not accepting insurance, managed care organization, or other third-party payors. However, this will be in full effect if this policy changes.
The agreed upon fee between Therapist and Client is $150.00/50 minute session. Therapist reserves the right to periodically adjust fee. Client will be notified of any fee adjustment in advance.
From time-to-time, Therapist may engage in telephone contact with Client for purposes other than scheduling sessions. Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Client’s request and with Client’s advance written authorization. Client is responsible for payment of the agreed upon fee (on a
pro rata basis) for any telephone calls longer than ten minutes. Therapist Charges $20.00 per 10-minute phone interaction that is not for the purpose of scheduling sessions. This includes phone contact with third parties.
Clients are expected to pay for services at the time services are rendered. Therapist accepts cash and checks. Bounced checks will incur an additional $20.00 fee. If payment is not rendered at the time the service is rendered a missed appointment fee will be charged. The missed appointment fee is the same as the cost of the regularly scheduled session.
Therapist is not a contracted provider with any insurance company or managed care organization. Should Client choose to use his/her insurance, Therapist will provide Client with a statement, which Client can submit to the third-party of his/her choice to seek reimbursement of fees already paid.
Client is responsible for payment of the agreed upon fee ($100.00) for any missed session(s). Client is also responsible for payment of the agreed upon fee for any session(s) for which Client failed to give Therapist at least 24 hours notice of cancellation. Cancellation notice should be left on Therapist’s voice mail at (650)-416-6388.
Therapist has a private voice mail system that allows Client to leave a message at any time. Therapist will make every effort to return calls within 24-48 hours, but cannot guarantee the calls will be returned immediately. Therapist does not return calls on weekends.
Therapist is unable to provide 24-hour crisis service. In the event that Client is feeling unsafe or requires immediate medical or psychiatric assistance, he/she should call 911, or go to the nearest emergency room.
On a case-by-case basis Therapist will accept home based Client(s) for the purpose of parent:child sessions. Additional informed consent and confidentiality paperwork , as well as an additional fee will apply. Availability for the service will vary on a case-by-case basis.
Termination of Therapy:
Therapist reserves the right to terminate therapy at his/her discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, Client needs are outside of Therapist’s scope of competence or practice, or Client is not making adequate progress in therapy. Client has the right to terminate therapy at his/her discretion.
Upon either party’s decision to terminate therapy, Therapist will generally recommend that Client participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Client.
By consenting to this document, Client acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement. Client agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy (or other mental health related activity) with Therapist. Moreover, Client agrees to hold Therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment.