CONSENT FOR THERAPY COUPLE

CONSENT FOR THERAPY

We __________________________& ________________________ have been informed about and accept to receive psychological services from __________________________, Permit # _____________.   We have met and discussed the theoretical framework and the techniques that they employ in the therapy session. We understand that we can discontinue therapy at any time but have been encouraged to persevere given that the therapeutic process can sometimes be difficult. I have been informed that we may experience uncomfortable feelings but have been reassured that working together with our therapist to tolerate these emotions may provide an opportunity to resolve our concerns and attain a more empowered place in our lives.

CONFIDENTIALITY

All client information is kept strictly confidential.  No information will be communicated to a third party without your permission. When records (i.e., reports) are requested by a third party (e.g., school, physician, insurance), your written authorization is required before any information can be released.

Please note: There are limits to confidentiality determined by the law. An example would be if a client discloses information that suggests imminent harm to self or another individual.  The psychologist/psychotherapist would be compelled to contact someone that can come to either your aid or that of the person in danger.

Please note: Also, any information regarding abuse/neglect, etc., of a minor, must by law be reported to the DPJ (child protection services). This does not include a victim of child abuse that has reached the age of majority disclosing past abuse unless there is still a minor at risk.

Please note: Confidentiality also does not apply if the law demands that information from a client file be disclosed (e.g., in the case of a criminal investigation).

However, with these limitations to confidentiality noted we do understand that in order to insure the best quality of services by our psychologist/psychotherapist they, without divulging any identifying information, discuss certain aspects of our situation with a supervisory team and if so we will be made aware of the names of persons on that supervisory team.

Contacting

Due to work schedules, our psychologist/psychotherapist may often not be available immediately by telephone. They will make every effort to return our call on the same day, with the exception of weekends, days out of the office and holidays. If unable to reach our psychologist/psychotherapist and in all cases of emergency we have been informed to contact our family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. For longer periods of time such as holidays we will be provided with an alternate person to call but only in the case of an emergency.

There may be times that we feel it necessary to contact our psychologist/psychotherapist by email. We do understand that the Internet is not a protected space and therefore we cannot be guaranteed the same level of confidentiality once we have put anything into cyberspace. Also we acknowledge that our psychologist/psychotherapist does not check their work email on any time off so will only expect a response once they are back in the office.

Costs

Each session will run 50 – 60 minutes in length. The therapy fees are reassessed each year for January 1 and the current rate has been discussed with my therapist. Phone support between sessions or any documents that need to be prepared will also be billed at the hourly rate. In order to cancel an appointment, we agree to give 24 hours notice or we will be billed for the session according to the guidelines of the Order of Psychologists of the Province of Quebec; and in order to cancel an appointment and ensure that the allotted time has been provided we agree to call the therapist at the number on their business card which we will have received at the first session. Sending an email does not guarantee that they will get the cancellation on time.

We have read and addressed any questions we have about this consent form with our psychologist/psychotherapist. In signing today, we confirm that we fully understand its contents.

Signed: _______________________________           Date:  ______________________________

Signed:  ________________________________        Date:  ______________________________