Informed
Consent
Informed Consent and Optional Questionnaire
INFORMED CONSENT
BENEFITS/RISKS
It is important that you know what to expect from telephone or
online psychotherapy. We therefore, ask you to read, sign and
mail us a copy of this informed consent as you begin your therapy.
Once you have established a relationship with one of our therapists,
the particulars of your situation will be discussed with you.
Your therapist will present our understanding of the issue with
which you want to work, our approach to the issue and the direction
that your therapy might take. You will have ample time to consider
what we propose before going forward.
Psychotherapy can be beneficial to most people who become involved
in the process, however this cannot be guaranteed. Your commitment
to your own growth will largely determine the benefits you will
gain. There may be times we will need to refuse to treat situations
we believe can not be handled appropriately, using the telephone
or the Internet.
CONFIDENTIALITY
All information communicated between therapist and client will
be held in confidence. No information will be released unless
you make such a request in writing. However, in order to keep
you and/or others safe, there is no confidentiality, should
you disclose incidents of child or elder abuse, or threats
of bodily harm to yourself or another.
In most legal proceedings, you hold the psychotherapist/patient
privilege, which would protect information about your treatment.
However, in the event of a lawsuit claiming emotional damage,
the psychotherapist/patient privilege would not be protected.
RECORD KEEPING
We will make brief, confidential notes of your sessions. Our
policy is to place these records on a back-up disk and store
them outside of our computers, to prevent access by unauthorized
persons.
CANCELLATION POLICY
Notify us either by telephone or email at least 24 hours before
your appointment and you will not be charged. You may either
request a reschedule or cancel your session. If your notification
is less than 24 hours of your scheduled session, you will forfeit
your payment..
I
have read and understand 1) the limits of psychotherapy, 2)
the limits of confidentiality and, 3) cancellation policies.
I am 18 years old or over.
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