Lakeridge Counselling & Consulting Services 

Couples and Individual Therapy in Orleans, ON

The following document will be discussed during the initial session; please take the time to review it and note any questions or concerns you may have, so we may properly address them.

Click here to access a printable version of the document

INFORMED CONSENT


Welcome to my practice.


In this document I will provide you with some information about my professional qualifications and approach to treatment. I will inform you about the benefits and risks of psychotherapy, client rights and responsibilities, confidentiality and payment policies, so that you may make an informed decision about your participation.


I would be glad to answer any questions or concerns you may have.


I am experienced with evidence-based psychosocial interventions for individuals and couples struggling with post-traumatic stress, substance abuse and mental health issues.   As a counsellor I have supported clients from diverse populations in various ways - from alleviating everyday stress and anxiety to managing mood, behavior and personality disorders. I am trained in the use of Motivational Interviewing, Adlerian Psychotherapy, Rational-Emotive Behaviour Therapy, Cognitive Behavioural Therapy, Logotherapy, Trauma-Informed Therapy, Solution-Focused Therapy. To meet the clients' individual needs, I use an integrative approach, drawing from therapeutic models such as Cognitive-Behavioural Therapy (CBT), Psychodynamic Therapies, Transactional Analysis, Dialectical Behavioural Therapy, Motivational Interviewing, First and Second Stage Trauma Treatment Methods.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of one’s life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness and helplessness. On the other hand, psychotherapy has been shown to have benefits for individuals who go through it. Therapy can lead to better relationships, solutions to specific problems, significant reductions in feelings of distress and improved self esteem, but there are no guarantees of what you will experience. Psychotherapy is a personal exploration and may lead to major changes in your life perspectives and decisions. Together you and I will work to achieve the best possible results for you.

I believe that clients have the capacity and resilience to resolve their own problems and make their own decisions. However, from time to time all of us need assistance, support and direction and I will work with you to establish goals for your therapy.


CONFIDENTIALITY

As your counsellor, I am committed to protecting your right to confidentiality; this means that the information you share during our counselling sessions will not be revealed to any other person or agency, without your written permission or request. I would like you to understand that there are certain situations in which I may be legally required to reveal the information obtained during counselling to a third party without your consent. Limits to confidentiality apply in circumstances under which:

  • You give me reason to suspect that a child may need protection, (i.e. child abuse or neglect). There is a legal obligation to inform the Children’s Aid Society if a client is placing a child at risk for sexual or physical abuse.
  • When I recognise that you may pose danger to yourself and/or others, i.e. expression of suicidal ideas, non-disclosure, exposure and transmission of infectious disease, planning to carry out activities that may violate and endanger the lives, health and security of others.
  • If counselling records are ordered to be produced by a court of law. In some cases, the judge is satisfied with a letter from the psychotherapist, such a letter would be discussed with you before it is sent to a judge.
  • If I must use information from your counselling record to defend myself in a professional liability lawsuit filed by you.
  • If the client is a health professional who is abusing or has sexually abused a client/patient, this must be reported to his or her regulatory body.
  • In case of medical, psychiatric or psychological emergency, I will contact your emergency contact, as identified by you, and/or the appropriate emergency response services.


Counselling Relationship: It is helpful to remember that our relationship is professional and not social. Our professional relationship is of utmost importance as we work together towards achieving your goals and bringing resolution and healing to your life.


Client Rights and Responsibilities:

  • You are responsible for coming to your session on time and not be under the influence of drugs or alcohol. 
  • You are responsible for paying the fees agreed upon.
  • You have a right to participate in developing an individual plan of treatment.
  • Every client in psychotherapy should have a treatment plan that describes general goals of therapy, and specific objectives the client will work on, to achieve their goals.
  • You have a right to receive an explanation of services in accordance with the treatment plan.
  • You have a right to participate voluntarily in and to consent to treatment.
  • You have a right to be treated in a manner which is ethical and free from abuse, discrimination, mistreatment, and/or exploitation.
  • You have a right to object to, or terminate, treatment.
  • You are in complete control and may end the counselling relationship at any time, though I do ask that you participate in a termination session.
  • If you are dissatisfied with my services, please let me know. If I am not able to resolve your concerns, you may contact the College of Registered Psychotherapists of Ontario to file a complaint.


VISITS AND FEES POLICY

Consultation and therapy visits last approximately 50 minutes. Sessions with couples and families may at times be 90 minutes in length. Psychotherapy typically involves weekly meetings; however, this may vary depending on the nature of your problem and individual needs. Special services such as written reports, letters, school or hospital visits are billed at the hourly rate. 

Fees are due at the time of service. This way, the account remains manageable and psychotherapy becomes a naturally budgeted expense. Payment can be made by cash, cheque, PayPal, internet transfer, or credit card. Online Credit Card payments are processed by Stripe. If you have extended health care insurance, you may be able to get reimbursed for some or all the fees, depending on your plan.  Please confirm your insurance coverage and limitations for services provided by a Registered Psychotherapist  with your insurance provider.  The policy for cheques that are returned by the bank is that the client will repay the amount of the cheque plus any bank processing charge. If no payment is made against an account for three months and no arrangements for payment have been made, therapy will be discontinued, and the debt will be put into collection. This action is an absolute last resort and not taken lightly.

Cancellations must be made with at least 24 hours notice, or charges for the missed session will be made, in full. Regular appointments are necessary for psychotherapy to work. The commitment you make to yourself and your mental health will be reflected in your determination to come to sessions even when it is difficult.


Fees and Services Schedule:

Counseling session …………………………………… $ 155 (+ HST)


Twenty-four hours notice of cancellation is required or the usual fee is charged.


If you have any questions about fees, please feel free to ask me.


IN CASE OF EMERGENCY

Sometimes clients have an emotional emergency, which requires immediate attention. The first recourse is to call the office. Your call will be returned as soon as possible, and you can usually expect to be given an appointment within 24 hours. If you feel that you cannot wait, or it is the middle of the night or during the weekend, you should contact your family physician, call 911, or go to the Emergency Department of any hospital.



PRIVACY POLICY


During our counselling relationship you will reveal personal information to me such as name, gender, date of birth, address, phone number, family status, employment information, names of family members etc.... I will be keeping progress notes, reports and assessments. It is my responsibility as a Privacy Officer at this Private Practice to protect your personal information, which I have in my possession.

  • Collection, use and disclosure of personal information will be done with your knowledge and consent, except in the above identified limits to confidentiality.
  • The collection, use, disclosure and retention of the client's personal information will be limited to the purposes for which it is collected and will be kept accurate, complete and up to date.
  • Unless there is an emergency, I will not collect private information about you

without your consent.

  • I collect and record only information that I believe is needed to provide you with

service.

  • To ensure quality of service and as part of my commitment to professional development engage in regular clinical supervision. Some of your information (date we met, topics we covered, progress, interventions, next steps for therapy) will be shared with my practice supervisor to find ways to improve services to you, to identify and correct risks and errors. Safeguards are in place to ensure protection of all clinical files in supervision.
  • The privacy of your information is protected through established procedures in

my office as follows: All private information is kept in a secure, locked filing cabinet. Electronic information about you is password protected.

  • Information about you occasionally may be seen by persons who are carrying out

an audit or a review of my practice.

  • Information about you will be disclosed to persons outside my office only with

your consent, except (a) in situations in which disclosure is justified by law or by

my profession’s code of ethics (e.g., risk of serious bodily harm; need for

confidential professional or legal consultation); and (b) in situations in which

disclosure is required by law (e.g., reporting a child in need of protection;

reporting a health professional who has sexually abused a client; a court order to

release information about a record).

  • When giving me permission to disclose information about you, the consent for release of information to third parties must specify the information to be released (i.e. full or partial record), the party to whom the information will be released, and how long is the consent valid for. However, if the information you do not want disclosed is clearly needed by the person receiving the information to provide you with appropriate

service, I am required by law to inform the person receiving the information that

you have refused consent to provide some necessary information.

  • It is my policy not to allow external researchers to see information about you,

unless you give your consent.

  • With only a few exceptions, you have the right to see your record of service and

to request copies of information in your record. Exceptions include the

possibility of harm to you or someone else, and confidential information in the

record about a person other than yourself.

  • If you believe that information in your record is not accurate, you may request

that I correct the information. If I do not agree with the correction you request,

you may file a notice of disagreement into your record.

  • I will speak with you directly to answer any questions you have regarding this Privacy

Policy, and to provide you with any further privacy practices or limits to

confidentiality that are specific to your situation.

  • If you would like more detailed information; at any time, would like to access or ask for a

correction of your record; have a concern about my privacy policies and procedures; or

have a complaint about the way your privacy has been handled, please do not hesitate

to speak with me.

  • If you have a concern or complaint and are not satisfied with my response, you may

contact the Information and Privacy Commissioner of Ontario (416) 326-3333 or 1-800-387-0073.


Form:

Click here to open a printable version of the Consent to Release Information Form, should you require it.


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