Client Forms

Informed Consent

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.

WHEN DISCLOSURE IS REQUIRED, OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client’s family members communicate that the client presents a danger to others.

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. For this purpose, I may also contact the person whose name you have provided.

HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier in order to process the claims. If you so instruct, 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 submitted or who has access to this information.

LEGAL PROCESSES: Sometimes clients become involved in a legal issue while they are in therapy or after therapy has been completed. Sometimes clients (or the opposing solicitor) want the records disclosed to the legal system. Due to the nature of the psychotherapeutic process and the fact that it often involves making a full disclosure regarding many matters, clients’ records are generally confidential and private in nature. Clients should know that 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 you or the opposing solicitor are considering requesting The Stress Less Clinic’s 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. (See also relevant section above: “WHEN DISCLOSURE IS REQUIRED, OR MAY BE REQUIRED BY LAW”)

CONSULTATION: I may consult with other professionals regarding my clients; however, each client’s identity remains completely anonymous and confidentiality is fully maintained.

ONLINE AND PHONE COMMUNICATION: It is very important to be aware that computers and unencrypted email, texts, and e-faxes communication (which are part of the clinical records) can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Emails, texts, and e-faxes are vulnerable to such unauthorized access since servers or communication companies may have unlimited and direct access to all emails, texts and e-faxes that go through them. While data on my computer is encrypted, emails, texts and e-fax are not. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. My computer 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 email, texts or e-fax 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 will honour your desire to communicate on such matters. Please do not use texts, email, voice mail, or faxes for emergencies.

RECORDS AND YOUR RIGHT TO REVIEW THEM: 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 necessary. 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 assesses 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 & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a message on my phone or email me and I will get back to you as soon as possible. If an emergency arises please contact The Samaritans or Befrienders Worldwide. Please note that I run an appointment based system and do not offer any emergency support.

PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee (see fee list) per session at the end of each session unless other arrangements have been made. 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, 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.

TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, I will discuss with you my working understanding of the problem, treatment plan, therapeutic objectives, and my view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, my expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.

TERMINATION: You have the right to terminate therapy and communication at any time. If you choose to do so, upon your request and if appropriate and possible, I will provide you with names of other qualified professionals whose services you might prefer.

DUAL RELATIONSHIPS: Despite a popular perception, not all dual or multiple relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs objectivity, clinical judgment or can be exploitative in nature. It is important to realize that in some communities, particularly small towns and small communities, multiple relationships are either unavoidable or expected. I will never acknowledge working with anyone without his/her written permission. Many clients have chosen me as their therapist because they knew me before they entered therapy with me, and/or are personally aware of my professional work and achievements. Nevertheless, I will discuss with you the often-existing complexities, potential benefits and difficulties that may be involved in dual or multiple relationships. Dual or multiple relationships can enhance trust and therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to advise me if the dual or multiple relationship becomes uncomfortable for you in any way. I will always listen carefully and respond to your feedback and will discontinue the dual relationship if it interferes with the effectiveness of the therapy or your welfare and, of course, you can do the same at any time.

SOCIAL NETWORKING AND INTERNET SEARCHES: I do not accept friend requests from current or former clients on social networking sites, such as Facebook. I believe that adding clients as friends on these sites and/or communicating via such sites can compromise their privacy and confidentiality. For this same reason, 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.

CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours (2 days) notice is required for re-scheduling or cancelling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification.

I have read the Informed Consent form for The Stress Less Clinic. I understand them and agree to comply with them:

At a face to face counselling session you will be asked to complete and sign an ‘Informed Consent’ form like this.  For online counselling (video, text, IM/Chat, Email or telephone) please complete the following, ensuring you tick the checkbox to agree to these terms.



Sharon Jones M.Ed, BACP, 19 Stow Park Avenue, Newport, NP20 4FL
Email: sjones@thestresslessclinic.co.uk

 

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  • DBS Checked
  • NZ Association of Counsellors