Lakeridge Counselling & Consulting Services 

Couples and Individual Therapy in Orleans, ON
Lora Bradford, RP

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. 

 

 

Psychotherapy is intended to help individuals and couples improve their sense of well-being and resolve issues and concerns adversely affecting the quality of their lives. This primarily talk-based therapy has been shown to have benefits for individuals who go through it, as it could lead to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved self-esteem and overall enhanced sense of functioning. It is important to note that psychotherapy is a personal exploration and there are no guarantees of what you may or may not experience. Your outcomes are largely related to your efforts and participation. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of one’s life, it is not unusual to experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness and helplessness. If this occurs, please make sure to talk to me, so I could adequately support you. 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 and map out steps for your therapy. 

I am trained and experienced in the application of evidence-based psychosocial interventions for individuals and couples struggling with relationship issues, depression, stress, anxiety and post-traumatic stress. 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. To meet the clients' individual needs, I use an integrative approach, drawing from therapeutic models such as Cognitive-Behavioural Therapy (CBT), Psychodynamic Therapies, Developmental Model of Couples Therapy, Emotionally Focused Couples Therapy, Dialectical Behavioural Therapy, Motivational Interviewing and Trauma-Informed Treatment Methods. 

 

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 agency, without your written permission or request. To ensure quality of service and as part of my commitment to professional development, I engage in regular clinical supervision. 

Consent for supervision: In the event that Your Therapist requires supervision by Dr. Bita, clinical psychologist, CPO#5333, for training purposes, You consent for Your Therapist to be supervised by Dr. Bita (which involves some degree of disclosure). You understand that you can request a meeting with Dr Bita, if You wish to do so she can be reached at director@clinicdrbita.com. You understand that information shared with Your Therapist including, but not limited to, formal psychological reports, evaluations, assessments, tests shall remain confidential and will not be disclosed to anyone, except if needed with Dr. Bita, without Your explicit written consent, unless one of the following situations arise: risk of harm to You, Your Child, or any other individual, subpoena/court order, demanding disclosure, evidence that the security or development of a child (or vulnerable adult) has been abused or is in danger of abuse. 

 

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. 

  • 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 being 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 to one hour and are offered by telephone, video or in-person. Telephone or video sessions remain the best way to prevent the spread of COVID-19; however, there are circumstances in which it would be necessary or appropriate to provide in-person services. Psychotherapy typically involves weekly meetings; however, this may vary depending on the nature of your problem and individual needs. 

Cancellations must be made with at least 24 hours notice, or charges for the missed session will be made, in full.

Changes to the cancellation policy due to COVID-19 (for in-person sessions only): Please note that if you have scheduled an in-person session and on the day of the appointment you notice any of the symptoms of COVID-19 (listed in your appointment confirmation and reminder email), you could call or email to request your appointment be switched to telephone or video format, or cancel the appointment with a minimum 1 hour notice. Note that no fees will be incurred for missed or canceled in-person appointments, due to COVID-19.

In case of a positive screening result, please seek COVID-19 testing at the assessment centre nearest to you. To book another in-person appointment you need to be symptom-free for at least 14 consecutive days (from the date of your deferred appointment) or provide proof of a negative COVID-19 test. LCCS reserves the right to block future appointment booking attempts should there be two or more missed appointments without a minimum of 1-hour cancellation notice. 

 

  • Fees for Telephone, Video or In-Person Services: Counseling/Psychotherapy Session (Individual or Couples) …………………………………… $ 155 (+HST) 

 

  • Special services such as written reports, treatment updates and letters are billed at the hourly rate. 

 

Fees are due at the time of service. Payment can be made by internet transfer, or credit card. Online Credit Card payments are processed by Stripe. E-transfer requests may be used for accounts that are overdue. If no payment is made against an account 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. 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.

 

IN CASE OF EMERGENCY 

Sometimes clients have an emotional emergency, which requires immediate attention. Lakeridge Counselling & Consulting Services is not a crisis centre and it does not provide crisis or emergency services. You are encouraged to call or email the office with the understanding that your call will be returned as soon as possible, within the next 24 business hours and you could expect to be given an appointment within 24 to 48 business hours. If you feel that you cannot wait, or it is the middle of the night or during the weekend, you are encouraged to contact your family physician, call Crisis Services Canada at  1.833.456.4566,  call 911, or go to the Emergency Department of any hospital.  

 

ACKNOWLEDGEMENT AND CONSENT

 

I accept, understand and agree to the terms of this agreement and provide voluntary consent to participate in psychotherapy and or counselling with Lora Bradford. I have had the opportunity to ask questions regarding these terms of service and confidentiality agreement and receive answers to my satisfaction. I understand that I may withdraw this consent at any time.

 

 

 Acknowledgement regarding in-person visits during COVID-19: I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by attending my therapy session and that such exposure or infection may result in personal injury, illness, permanent disability, or death. I understand that the risk of becoming exposed to or infected by COVID-19 at the therapist's office may result from the actions, omissions, or negligence of myself and others (visitors, business owners, employees at the business building where the office is located). I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at the psychotherapist’s office . I hereby agree not to sue, discharge, and hold harmless, the psychotherapist, of and from any claims, including all liabilities, actions, damages, costs or expenses of any kind arising out of or relating thereto; whether a COVID-19 infection occurs before, during, or after participation in any counselling/psychotherapy (in-person) visit to the psychotherapist’s office. 

 

 

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. 

  • 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 1-800-3870073. 




Form:

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


UA-120260081-1