Consent to Treatment/Written Disclosure
Welcome!
Before we get started together, it is my duty to tell you some things. Some I am legally obliged to tell you; some are things I want to clearly say so that you can know what will happen in the next steps of therapy. Take your time with this and ask any questions that you have before signing. I am glad you are here.
Confidentiality
Be assured that I will take every measure possible to guard your name, reputation, and integrity, and to treat you honorably and respectfully in all our transactions. All information disclosed within sessions and the written records pertaining to those sessions is confidential and may not be revealed to anyone without your written permission except where disclosure is required by law (see Disclosure when/if required by law Section below for further details). I safeguard your information in line with the guidelines set out by the BC Association of Clinical Counsellors (BCACC). If you have any questions about these guidelines, or of my qualifications, you can ask me or contact the BCACC directly by phone, mail, or email at: The BC Association of Clinical Counsellors - BCACC#204 – 780 Tolmie AvenueVictoria, BC, Canada V8X 3W4phone 1.800.909.6303 info@bcacc.ca
At all times, and in all my professional activities, I am accountable to the code of ethics and standards of practice of the BCACC. If we happen to come into contact outside of therapy, I won’t acknowledge you in order to protect your confidentiality. You may greet me or speak with me if you so chose, but I will not initiate.
Relationships and Confidentiality
If you are seeing me for relationship counselling I will be seeing you individually as well as together. While what you tell me is in confidence, I am not able to be a secret keeper of information revealed by one party of a relationship that I feel affects the other party or the relationship as a whole. When this sort of material is related I will work with you to plan how the material will be expressed to the other party.
Consultation
I consult regularly with other professionals regarding clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained. I do this in pursuit of providing you the best care possible.
Disclosure when/if required:
In certain circumstances I have a duty to break confidentiality.The following standard practices regarding confidentiality are very important and you should be aware of them. Please discuss any concerns you have about them with me. I have a duty to report where there is a reasonable suspicion of child, dependent, vulnerable adult, or elder, abuse or neglect; warn those in danger, which may include authorities when I cannot contact those in danger, if there is a situation when I have knowledge that people, including the client, may be in danger; and respond to court orders seeking information. Specifically:
If you are under the age of 19 and disclose abuse (sexual and/or physical) by a specific person, the abuse must be reported to the Ministry for Children and Family Development.
If you are over the age of 19 and disclose abuse (sexual and/or physical) by a specific person who has access to people under the age of 19, the abuse must be reported to the Ministry for Children and Family Development.
If there is a serious possibility that you may harm yourself or others, we must take reasonable action, which may include contacting the police or other responsible authorities.If you are impaired by drugs and/or alcohol and intend to drive, we must report this to the Motor Vehicle Branch and/or the police.
In some court actions, our counsellors and/or their records may be subpoenaed. This is not a frequent occurrence, however, you should be aware of this possibility.
In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. I will use my clinical judgment when revealing such information. In such cases I have a duty to respond, but not necessarily to comply, with request for disclosure. I will not release records to any outside party unless authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client.
Emergency
If there is an emergency during therapy, or in the future after termination, where I become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care.
Health Insurance & Confidentiality of Records
Disclosure of confidential information may be required by your health insurance carrier or other party in order to process the claims. If you so instruct me, only the minimum necessary information will be communicated to the carrier. I have no control over, or knowledge of, what insurance companies do with the information I submit or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and computers are inherently vulnerable to hacking and unauthorized access. Medical may be legally accessed by law enforcement and other agencies, which may put you in a vulnerable position.
Litigation
Sometimes patients become involved in litigation while they are in therapy or after therapy has completed. Sometimes patients (or the opposing attorney, in a legal case) want the records disclosed to the legal system. Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters, clients’ records are generally confidential and private in nature. Serious consequences can result from disclosing therapy records to the legal system. Such disclosures may negatively affect the outcome of custody disputes or other legal matters and may negatively affect the therapeutic relationship. If anyone is considering requesting disclosure of the records, I will do my best to discuss with you the risks and benefits of doing so. As noted in this document, you have the right to review your own therapy records anytime. You own your information.
Consultation
I consult regularly with other professionals regarding clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained. I do this in pursuit of providing you the best care possible.
Emails, cellphones, texts, computers, and faxes
It is very important to be aware that computers and any electronic communication (which are part of our records) can be rather easily accessed by unauthorized people and, hence, can compromise the privacy and confidentiality of such communications. Emails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all electronic communication that go through them. While data on all my computers is encrypted, emails, texts and e-faxes are not. It is always a possibility that e-faxes, texts, and emails can be sent erroneously to the wrong address and computers. My laptop is equipped with a firewall, a virus protection and a password, and I back up all confidential information from my computer on a regular basis onto an encrypted hard-drive. If you communicate confidential or private information via unencrypted emails, texts or e-faxes or via phone messages, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and I will honor your desire to communicate on such matters in these mediums. Please do not use texts, emails, voice mails, or faxes for emergencies.
Records and your right to review them
Both the law and the standards of profession require that I keep treatment records for at least 7 years, in accordance with BCACC recommendations. Please note that clinically relevant information from emails, texts, and faxes are part of the clinical records. Unless otherwise agreed to be necessary, I retain clinical records only as long as is mandated by British Columbia and Canadian law. If you have concerns regarding the treatment records, please discuss them with me. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. In such a case, I will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, I will release information to any agency/person you specify unless I assess that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couple and family therapy, I will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.
Telephone and Emergency Procedures
I don’t provide after hours care and am not accessible by phone outside of office hours. Please do not use text, fax, or email. I do not always check these daily. If you need to contact me between sessions, please leave a message at the answering service (778) 683-3395 and your call will be returned as soon as possible. I check my messages a few times during daytime only, unless I am out of town. If you are running late for a session you can text to this same number. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away choose from the following:
If you are in a situation that involves immediate risk of harm to self or others, please call 911.
call BC Crisis line at 310-6789 (do not add 604, 778 or 250 before the number). You can call 24 hours a day to connect to a BC crisis line, without a wait or busy signal. The crisis lines linked in through 310-6789 have received advanced training in mental health issues and services by members of the BC Partners for Mental Health and Addictions Information.
Call 1-800-SUICIDE (1-800-784-2433) to get help right away, any time of day or night. It’s a free call.
For children and youth aged 5 to 20. Call 1-800-668-6868 to speak to a professional counsellor, 24 hours a day. It’s free, confidential, anonymous and available across Canada. They can also refer you to local services and resources. Kid’s Help Phone is available in English and French.
Payments & Insurance Reimbursement
Clients are expected to pay the standard fee of $120.00 (individual) or $150 (relationship) per hour session prior to or at the end of each session, and ‘an hour session’ is limited to 50 minutes of client therapist time. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, with a minimum charge of $50, unless indicated and agreed upon otherwise. Please notify me if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, I will provide you with a copy of your receipt after each session, which you can then submit to your insurance company for reimbursement, if you so choose. Not all therapy is reimbursed by insurance companies and I do not have insight into insurance coverage. It is your responsibility to verify the specifics of your coverage.If your account is overdue (unpaid) I can use legal or other means to obtain payment.
Therapeutic Orientation
If you choose to work with me, I will be working with you in the role of a clinical counsellor. I hold two master’s degrees that inform my practice, one in counselling and one in theology, and I am a Registered Clinical Counsellor (RCC) with the British Columbia Association of Counsellors ( #17847). I work from a variety of theoretical viewpoints while being strengths-based. My therapeutic style is adapted to each individual’s unique situation. Some of these therapies include; person-centered, solution-focused, narrative, cognitive-behavioural, and Adlerian theory.
The Proposed Course of Treatment/Scope of Practice
The process of therapy relies on the participation of you, the client, and me, the therapist. As the treatment begins and progresses, I will update you on what course of treatment I propose. I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation, and as therapy progresses, we will work collaboratively in choosing a course of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, or about the treatment plan, please ask and I will answer honestly and to the best of my ability. Change will sometimes be easy, but more often it will be slow and perhaps frustrating. There is no guarantee that therapy will yield the intended results. During the course of therapy, I am likely to draw on various approaches according to the problem that is being treated and my idea of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, system/family. I do not provide medication, prescription recommendation, diagnoses, nor legal advice, as these activities do not fall within my scope of practice.
Treatment Plans
Within a reasonable period of time after the initiation of treatment, I will discuss with you my concept of the problem you have come with, a treatment plan, therapeutic objectives, and possible outcomes of treatment. If you have any questions about any of the procedures used in the course of therapy, risks, or about the treatment plan, please ask and you I will do my best to answer. You have the right to ask anything in regard to your treatment. I am here to serve you.
Termination
This is your therapy and you have the right to terminate it at any time for any reason. At any point where it may be helpful, I would be pleased to provide referrals to qualified colleagues. If you choose to terminate therapy with me completely I will still, if requested, provide you with names of other qualified professionals whose services you might prefer. As set forth above in the section on treatment plans, after the first couple of meetings, I will assess if I can be of benefit to you. I do not work with clients who I do not think I can help. In such a case I may offer you referrals that you can contact. If at any point during psychotherapy I either assesses that I am not effective in helping you reach your goals or perceive you as non-compliant or non-responsive, and if you are available, I will discuss with you the termination of treatment. If you request it, I will do what I can to help with the transition.
Social Networking and Internet Searches
At times, I may conduct a web search on my clients on general search engines before the beginning of therapy or during therapy. This doesn’t happen much, but it might if I think it may be useful to your treatment. If you have concerns or questions regarding this practice, please discuss them with me. I do not accept friend requests from current or former clients on social networking sites, such as Facebook, and I do not search these sites. For my own privacy, I request that clients not communicate with me via any interactive or social networking web sites.
Audio or Video Recording
Unless otherwise agreed to by all parties beforehand, there shall be no audio or video recording of therapy sessions, phone calls, or any other services provided by me or you, the client. If audio or video is recorded, it is assumed that this will be used for therapeutic or educational uses, not for entertainment purposes, artistic projects, humor, podcasts, or financial gain.
Cancellation
Scheduling of an appointment involves the reservation of time specifically for you, and so a minimum of 48 hours (2 days) notice is required for re-scheduling or canceling an appointment. Any missed session will be charged at a full rate without 48 hours notice.
Accountability
If you have a concern about any part of your counselling experience, please let me know so we can discuss it. If you are not satisfied with our resolution, or if you don’t feel comfortable to discuss it with me, you can submit a written grievance to the:
BC Association of Clinical Counsellors #204 – 780 Tolmie Avenue Victoria, BC, Canada V8X 3W4 phone 1.800.909.6303