Authorization for Coordination of Care
Coaching and Provider Communication
Purpose of Authorization
The purpose of this authorization is to permit communication between my coach and my psychiatric provider in order to support coordination of care and alignment of goals related to my coaching services and overall wellbeing.
I understand that:
- Coaching is a professional development and personal growth service.
- Coaching is not psychotherapy, counseling, mental health treatment, or medical care.
- My psychiatric provider is solely responsible for any diagnosis, treatment decisions, and medication management.
- This authorization allows limited communication intended to support my coaching process and wellbeing.
Information That May Be Shared
I authorize the following types of information to be shared between my coach and psychiatric provider:
- Coaching goals and areas of focus
- General observations related to my functioning or wellbeing
- Progress or challenges relevant to coaching goals
- Recommendations that may support coordination between coaching and psychiatric care
- Scheduling coordination if needed for consultation
The following information will not be disclosed unless separately authorized:
- Psychotherapy notes
- Detailed psychiatric records
- Personal history unrelated to coaching services
Methods of Communication
Communication may occur via:
- Phone
- Secure video meeting
- Written correspondence
Right to Revoke Authorization
I understand that I may revoke this authorization at any time by submitting a written request to my coach and/or psychiatric provider. Revocation will not apply to information already disclosed prior to the revocation.
Coach Acknowledgment
Coach Name (Printed): Donae Cannon
Signature: Donae Cannon
