Disclosure and Consent for Treatment 

Welcome to my practice! This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them. When you sign this document it will represent and agreement between us.

Psychological Services

Therapy is not easily described in general statements. It varies depending on the personalities of the therapist and the client and the issues that are being addressed. There are many different methods I use in my practice including but not limited to: Solution-Focused counselling, Cognitive Behavioural Therapy, Narrative Therapy, Motivational Interviewing, Family Systems Therapy, Family Constellations Therapy, Gottman Couples Therapy, Emotion Focused Therapy, Energy Psychology (Emotional Freedom Techniques and Comprehensive Energy Psychology), Spiritually Directed Therapy, Embodied Awareness, Mindfulness Approaches, and Client Centred Approaches. Please feel free to ask about any of these approaches at anytime.

The type of therapy that I practice calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on the things we  talk about during our sessions. The therapeutic process is collaborative; your knowledge and life experiences will contribute to the therapeutic change you experience. Throughout the therapy process I will recommend activities or exercises for you to do at home that will contribute to the success you experience. In order for therapy to be most successful, you will have to work on things we talk about. By signing this document you are agreeing to participate in each session to the best of your ability. 

Therapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings or the recall of unpleasant events in your life. On the other hand, therapy has also been shown to have benefits for people who go though it. Therapy often leads to better relationships, better problem solving and coping skills, solutions to specific problems, significant reductions in feelings of distress, releasing of unwanted habits and changing of negative thoughts and feelings. However, there are no guarantees of what you will experience.

There may be risks of not receiving counselling for your concerns. These risks may include experiencing continued distress or watching the problem get worse. There are alternatives to counselling which may be beneficial including medical interventions (such as medication), massage, taking a holiday, or other personal options. Only you can determine if counselling is best for you. 

Sessions

A one-hour appointment generally includes 50 minutes of client contact and 10 minutes of record-keeping. I offer the time booked within my practice and I offer a follow-up of key points to help support my clients in their work (with your consent). 

Therapy involves a large commitment of time, money and energy, so you should be very careful about the therapist you select. If you have questions about how I work, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

Fees and Payment

I charge $250 per hour for 50-minute appointments and all other professional services, I will break down the hourly cost for periods of less than one hour. Sessions beyond 50 minutes are billed at a reduced rate (60 mintues = $270, 75 mintues = $310, 90 mintues $330). Standard rates apply for sessions that go over time. We are both responsible for ending sessions on time.

Other services include report writing, email support, video meetings, telephone conversations lasting longer than 5 minutes, developing a personalized plan for you outside of our therapy time, attendance at meetings with other professionals you authorized, preparation of records or treatment summaries, and time spent performing any other service you may request of me. Payment schedules for these services swill be discussed and agreed to when they are requested. Please feel free to ask me about any of these services. 

Payment for the session or services occurs at the time it is held, unless we agree otherwise. Payment can be made via cash, cheque, VISA, MasterCard, e-transfer and Paypal. A receipt is provided for each session and it is the client's responsibility to submit it to their insurance plan for possible reimbursement. 

Cancellation

Once an appointment is scheduled, you will be expected to pay for the full session cost unless you provide 72 hours advance notice of cancellation or unless we both agree that you were unable to attend due to circumstances beyond your control before additional sessions are booked/held. If it is possible, I will try to find another time to reschedule the appointment. Should cancellation be considered because weather or other current circumstances prevent the client from travelling to the office, I will be pleased to consult by phone during the scheduled appointment time. 

On rare occasions, I may need to cancel a session due to illness or emergency. I this event, all efforts will be made to reschedule as soon as possible. 

Evaluation and Consultation

In order to serve my clients to the best of my ability I believe it is important to engage in a process of evaluation. This evaluation comes from colleges and clients. I may ask you to complete questionnaires that will help me to determine your satisfaction and progress. These questionnaires will be used to research the effectiveness of the services that I provide.

Also, I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless that I feel it is important for our work together.

Insurance and Reimbursement

You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course I will provide you with whatever information I can based on my experience. You will be provided with an official receipt with my registration number as a Registered Psychologist with the College of Alberta Psychologists.

If you submit claims online, your insurance company may call be to verity the date and cost of the session. Please initial here if you grant me permission to disclose this information _____________ (Client initial).

Contacting Me

With any therapy process there is ongoing personal work that often happens between sessions. Wrestling with important concerns can often bring up additional questions and reflections. The best option is to discuss what is coming up between sessions when we meet at our next session. I would encourage you to keep a list of questions that come up as a part of your process to be addressed at your next session. For non-urgent concerns I recommend scheduling an additional session in order to honour the process to allow adequate time to dive in deeper. Due to the nature of my practice I will respond first to urgent matters and I will make a note of additional concerns to bring up at our next appointment. 

I request that phone support between scheduled sessions is limited only to emergency situations where there are active safety concerns. While I am usually in my office during business hours, I am unable to answer my phone when I am with a client. When I am unavailable, my office telephone is answered by a confidential voicemail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. In order to protect your confidentiality I request that you contact me by phone or by email or my secure online booking system.

If you are unable to reach me and feel that you can't wait for me to return your call, contact your family physician, call 911, or visit the nearest emergency room and ask or the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. 

Professional Records

I keep treatment records, if you request, you are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. 

Confidentiality

All information that is shared in counselling is confidential and no information will be released to any third party without explicit written consent from you according to the Freedom of Information and Protection of Privacy Act (FOIPP) and/or Health Information Act (HIA). 

In general, law protects the privacy of all communications between a client and a therapist and I can only release information about our work to others with your written permission. But there are a few exceptions. 

1. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceeding involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. 

2. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client's treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I just file a report with the appropriate agency.

3. If I believe that a client is threatening serious bodily harm to themselves or others, I am required to take protective actions. These actions may include notifying the potential victim or contacting the police. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. 

These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action. 

4. If you are a minor, parental consent is required for me to meet with you. Conditions of confidentially regarding minors need to be negotiated with a parent/guardian.

Out of respect for your privacy and confidentially, I will not approach you in a public forum should we ever run into on another outside of therapy. If you wish to approach me, you are very welcome to do so. While this written summary of exceptions to confidentially should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you might have. 

Additional Rights

To be treated with respect, dignity and without discrimination according tot he Canadian Human Rights Act.

To refuse and/or end treatment, and/or to withdraw consent at anytime:

Counselling services can be discontinued at any time by either you or your counsellor.

Consent may be withdrawn at any time without prejudice wither verbally or in writing.

You may make a formal complaint should you be unable to resolve an issue between us by contacting:

The College of Alberta Psychologists

2100 SunLife Place 10123 - 99 Street Edmonton, AB T5J 3H1

Phone: (780) 424-5070 or (toll free in Alberta) 1-800-659-0857

Consent for Treatment

By signing this document you acknowledge that you have read, understood, and agreed with the information above. Also, you are indicating that you understand that results vary and you acknowledge that the signed therapist cannot guarantee results. In addition, you are agreeing that you have addressed any concerns or questions that you had with your therapist and you give your full consent to engage in and receive therapy.

APA INFORMED CONSENT CHECKLIST FOR TELEPSYCHOLOGICAL SERVICES

Prior to starting video-conferencing services, we discussed and agreed to the following:

- There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.

- Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the others person(s).

- We agree to use the video-conferencing platform selected for our virtual sessions, and the psychologist will explain how to use it.

- You need to use a webcam or smartphone during the session.

- It is important to be in a quiet, private space that is free of distractions (including cell

phone or other devices) during the session.

- It is important to use a secure internet connection rather than public/free Wi-Fi.

- It is important to be on time. If you need to cancel or change your tele-appointment,

you must notify the psychologist in advance by phone or email.

- We need a back-up plan (e.g., phone number where you can be reached) to restart the

session or to reschedule it, in the event of technical problems.

- We need a safety plan that includes at least one emergency contact and the closest ER

to your location, in the event of a crisis situation.

- If you are not an adult, we need the permission of your parent or legal guardian (and

their contact information) for you to participate in telepsychology sessions.

- You should confirm with your insurance company that the video sessions will be

reimbursed; if they are not reimbursed, you are responsible for full payment.

- As your psychologist, I may determine that due to certain circumstances, telepsychology

is no longer appropriate and that we should resume our sessions in-person.