Consent to Treatment &Confidentiality Form
Benefits and Limitations of Psychotherapy
Gestalt therapy works at an experiential and emotional level. While most people find this helpful, there is no guarantee of improvement for every situation. You will be asked to consider your beliefs, feelings, perceptions, and behaviours resulting in insights which, at times, may be outside your comfort zone.
Like any relationship, a therapeutic one can occasionally have awkward moments. I will make mistakes. This includes saying too much or too little, forgetting things that are important or otherwise missing what matters most to you. Even if it’s small, if something in session doesn’t sit well with you, please voice it and teach me how to support you better.
Ongoing Consent Process
At all times, you have the right to decide on the degree of your participation, and to ask for further explanation and support. At all times, you have the right to choose not to discuss a topic, or to terminate the session or the service. You can and should withhold consent whenever you need. You decide what’s best for you.
I am almost always happy with a handshake or hug if that's something you find comforting. However, in order to prevent clients from feeling obligated, I will never initiate. If you want one, just ask.
Payment for services agreement
- Psychotherapy sessions are normally 50 minutes long, with an option for 1 hour and 20 minute sessions for 1.5 times the base session rate.
- Payment is due within 24 hours of each session by either cash or interac email transfer. Receipts will be provided upon request.
- I require 24 hours notice of any changes or cancellations to appointments, by email or by telephone. You will be charged the full fee for sessions missed or cancelled with less than 24 hours notice. I also give exception for cancellations for matters outside of the client's control including occasional emergencies, severe and sudden illness, and weather that is unsafe to travel in.
Protecting Your Confidentiality
- Everything you discuss with me in a session is confidential. As required by law, I make notes of key points from each session that are kept for 10 years. I keep my notes digitally under three passwords and two levels of encryption.
- The notes are a summary of what was said in the session. You have the right to request a copy of your counselling file at any time.
- Communication about scheduling is allowed by text, email and phone. The government deems text and email to be insecure forms of communication, so no personal or emotional information should ever be shared in these forms.
- If ever we encounter each other outside of the therapy office, I will do my best to not reveal I know you or are your therapist. This is for your privacy. You are welcome to approach me and reveal to others that you are my client.
Limits to Confidentiality
The government requires therapists release your confidential information in limited circumstances:
- Your counselling record is subpoenaed by a court.
- You disclose that a child under 16 is being abused or neglected.
- You disclose that a regulated health professional has sexually abused you or another person. A report can be made without naming you if you choose.
- You disclose that you have an immediate concrete plan to end your life or someone else's. However voicing thoughts, worries, or concerns about this is important and healthy. If you have any questions, please ask.
My commitment is to talk with you and explore any of this before taking steps to release any confidential information. If you have questions about this or any other part of the consent form please don't hesitate to ask.