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CLIENT INFORMATION AND STATEMENT OF UNDERSTANDING
Consent for Assessment and Treatment
I consent to a clinical assessment and counseling through Integrative Counselling Services. Early in my treatment, my therapist will discuss my goals for therapy, an expected length of therapy and work with me to develop a suitable approach toward meeting my goals.
Length of Session
Each session will last 50 minutes for therapy and 10 minutes for note taking and file management.
Attendance Agreement
I agree to attend all scheduled appointments. If I am unable to attend a scheduled appointment, I will notify my therapist at least 24 hours prior to my scheduled appointment. I understand that it is my responsibility to reschedule any appointments that I cancel or miss. I understand that if I do not attend three (3) consecutive appointments without providing 24 hours notice, my file will be reviewed and a determination made as to whether or not I will remain a client at that time. If I find it difficult to attend scheduled appointments, I will discuss this difficulty with my therapist.
Policy on Confidentiality
All information pertaining to my assessment and treatment is treated with respect and discretion. I understand that information relevant to my case shall remain confidential except when:
- there is a risk of harm to myself or others;
- there is reason to suspect child abuse or neglect;
- the clinical file and/or therapist has been subpoenaed;
- internal review of services and program planning, quality of care provided, therapist evaluation.
My therapist will request written and/or verbal consent from me before consulting with anyone else. I understand that when information is disclosed, only that portion that is relevant to the request is shared. I have a right to specify which information may be shared and I know that I can withdraw my consent at any time. Once my file is closed with Integrative Counselling Services, I understand that all consents are void. I have read or been informed of this information and policies. I confirm that I am signing this statement willingly and that I understand and agree to the conditions outlined above.
Client Name: (Please Print) Client Signature:
Date:
(Please print this page and bring with you to your first appointment.)
