PLEASE COPY AND EMAIL THIS FORM TO : Willown_Counselling@hotmail.com

CONSENT FORM FOR COUNSELING & THERAPY

 Counseling and therapy works in part because of clearly defined rights and responsibilities held by each person. As a client in therapy, you have certain rights that are important for you to know about. There are also certain limitations to those rights as well as client responsibilities that you should be aware of. The following outlines these important aspects of therapy.

Client's Right to Confidentiality

With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. Your therapist cannot and will not tell anyone else what you say, or even that you are in therapy at our Center without your prior written permission. Your therapist will always act so as to protect your privacy. You may direct your therapist to share information with whomever you chose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend sessions with you.

If you elect to communicate with your therapist by email, please be aware that email is not completely confidential. All emails are retained in the logs of your or our internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. For privacy and other purposes, your therapist will not add you on any Social Media.

 The following are legal exceptions to your right to confidentiality. Your therapist would inform you of any time when your therapist thinks he/she will have to put these into effect.

1. Harming Others. If your therapist has good reason to believe that you will harm another person, he/she must attempt to inform that person and warn them of your intentions. Your therapist must also contact the police and ask them to protect your intended victim.______initals

 2. Harming a Child or Vulnerable Adult. If your therapist has good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give your therapist information about someone else who is doing this, your therapist must inform Child Protective Services within 48 hours and Adult Protective Services immediately. _______initals

3. Harming Yourself. If your therapist believes that you are in imminent danger of harming yourself, your therapist may legally break confidentiality and call the police or the local crisis team. Your therapist will attempt to explore all other options with you before he/she takes this step. If at that point you are unwilling to take steps to guarantee your safety, your therapist will call the crisis team to ensure your safety   ______initals

Record-keeping.

Your therapist keep records of the professional services provided, noting that you have been here, what interventions happened in session, what interventions were recommended outside of therapy, and others topics discussed relevant to therapy. Because these records contain information that can be misunderstood by someone who is not a mental health professional, it is our general policy that patients may not review them directly; however, your therapist will provide at your request a treatment summary unless your therapist believes that to do so would be emotionally damaging. If that is the case, your therapist will be happy to send the summary to another mental health professional who is working with you. _______initials’

Goal Setting, Progress, & Measurement.

As early as possible, you will solidify treatment goals with your therapist, and to the degree possible, your therapist will identify indicators of progress and will begin monitoring your progress throughout the course of therapy. Some outcomes are more difficult to monitor than others, and so your therapist will work with you to best measure and track your progress over time. Even though you have achieved your initial goals, your therapist may work with you to identify any new and additional goals that are meaningful for you to work on in therapy. Termination typically occurs once these outcomes are achieved.________ initials

Other Rights of the Client

 1. You May Ask Questions. You have the right to ask questions about anything that happens in therapy. Your therapist is always willing to discuss with you why you are doing what you are doing in session.

 2. You May Refuse/Make Suggestions. While your therapist is trained to offer you helpful suggestions, you have the right to refuse any suggestion made by your therapists and/or ask your therapist to go in a different direction that you think will be helpful for you.

Client Cancellation Policy.

As with many organizations, we have a cancellation policy in place that you should be aware of. You are responsible for informing our Support Staff in advance when you need to cancel or reschedule your appointment. This can be done via phone. _______initials

Late Rescheduling/Late Cancellation Fee.

If you reschedule or cancel your appointment after 6pm on the day prior to your session (for example, after 6pm on Friday for your Saturday appointment), this is considered a 'Late Rescheduling/Late Cancellation,' for which you will be charged a Late Cancellation' fee of 100% .In order to avoid this fee, please notify our Staff 24 hrs ahead if you need to cancel or reschedule your appointment._______ initials

No Show Fee.

 If you do not show up for your session without notifying us in advance, or if you call us to cancel your session within 24 hours prior to your session this is considered a 'No Show,' for which you will be charged a 'No Show' full charge ( full session amount).In order to avoid this fee, please notify our Staff  24 hrs prior to that time if you need to cancel or reschedule your appointment._____ initials

Please note that, even if you have health insurance covering services at our Center, most insurance companies do not cover late cancellation/no show fees, and so you will be responsible for these fees even if you have insurance.________ initials

Payments.

ALL  apts are agreed to be paid at time of booking, in accordance to client/therapy agreements. Fees are to be sent via e-transfer to Willown_Counselling@hotmail.com

An electric receipt will be issued to you for submission to personal benefits, please note we are in the process of setting up direct billing to insurance companies. Please make sure your insurance covers Therapy with a Registered Social Worker.

Emergency after hours appointments, will be billed at a rate of $75.

☐ Please check this box indicating that you are aware of, understand, and agree to the Cancellation Policy above.

 Late Arrivals.

 You are responsible for coming on time to your sessions, which last for 55 minutes. If you arrive late, that time cannot be made up (since there are often other clients scheduled after you). If youa re more than 10 minutes late, your apt will be cancelled._______initials

Client Consent to Psychotherapy

I have read this consent form, I had sufficient time to be sure that I considered it carefully, I asked any questions that I needed to, and I understand it. If I have any remaining questions, I may ask them now. I understand the issues of confidentiality, my rights and responsibilities as a client, and my therapist's responsibilities to me. I understand everything above, and I agree to receive services at the Center.

 Client’s Name (print):_____________________________________________

Client’s Signature:_____________________________

Today’s Date:________________________________