Registered Psychologist License # 5099
INFORMED CONSENT STATEMENT FOR PSYCHOTHERAPY AND COUNSELLING
Welcome to Flow Psychology and to therapy with Elizabeth Forbes. I truly believe that each person whose path I cross – is meant to be here. Thank you for coming! Counselling, or therapy, is a relationship that works in part because of clearly defined rights and responsibilities held by each person. It is important for us to communicate up front (thus the ‘informed’ part of consent). Please ask any questions or discuss any of
this document with Beth at any time during therapy.
As a client engaging in this process you have certain rights that are important for you to know. As a Psychologist, I have responsibilities to you (client), the laws in Alberta and in Canada, and to my governing bodies, the College of Alberta Psychologists (CAP) and the Canadian Psychologists Association (CPA). I am a member in good standing of CAP and CPA and adhere to the respective Code of Ethics. This means there are certain limitations to your rights to confidentiality that you have the right to know about.
MY RESPONSIBILITIES TO YOU AS YOUR THERAPIST
With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior written permission. (yes, we have a form for that ).
At times you may want me to share information with pertinent people and you may request an (ROI) Release of Information (in writing) to share information about you with others involved in your care. You may direct me to share information with whomever you chose (family included), and you can change your mind, and revoke that permission at any time. You are also protected under the provisions of the Freedom of Information and Protection of Privacy Act (FOIP). All ROI’s are valid for one year from the date of signing unless otherwise stated.
If you elect to communicate with me via electronic means (text, email, voice mail, social media, etc) at some point in our work together, I am willing to respond briefly by return communication, but please be aware that email and other electronic media forms are not completely confidential. I do not use an encrypting program on email at this time however, I am the only person that has access to my email – and it is passworded and coded carefully (your initials vs your name).
Case notes are hard copy (I am old school) and are stored according to CAP standards which means locked in a cabinet in a locked room. I am the only practitioner that has access to any of your confidential information.
If we mutually agree to engage in telepsychology, please be aware of the limitations around this. These may include: a potential for is understandings when visual cues are absent/limited. It would be prudent to seek clarification on the part of all parties when necessary. There may potentially arise technology related and/complications (poor internet speed, equipment failure, etc). It is necessary to consider that any information transmitted via internet may not be secure. Should a breach occur, Elizabeth Forbes must notify the Office of the Information and Privacy Commissioner for further instruction/guidance. This would be related to limits of confidentiality, in that your personal information will likely have to be provided to resolve the potential issue. Crises and issues of immediate safety concerns will be managed (safety, emergencies, etc) through the process of contacting emergency contacts and/or including additional emergency services when Elizabeth Forbes, deems necessary.
The following are legal exceptions to your right to confidentiality.
** If I have reason to believe that you have intent to harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.
- If I have reason to believe that you are abusing or neglecting a child or vulnerable adult, or an animal, or if you give me information about someone else who is doing this, I will inform the appropriate governing bodies immediately.
- If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call emergency services.
- If your file is subpoenaed. I will advocate to limit the information that is admissible, but the court may access your file.
Any additional costs/fees, etc., related to the above exceptions are the sole responsibility of the client and not Elizabeth Forbes, and/or Flow Psychology.
I keep brief records of each session documenting the date and time of our session, themes we discussed (emotional regulation, distress tolerance, etc) progress reports from the client’s perspective, and interventions utilized in the session (you may request a copy of the form I use for case notes). My records are kept private and no information is shared with others. Files are stored and kept for kept for a minimum of 10 years, as per Alberta’s/Canada’s legal requirements.
If a third party, such as an insurance company, is paying for part of your bill, I am normally required to give a diagnosis to that third party in order to be paid. Diagnoses are technical terms that describe the nature of your problems and something about whether they are short-term or long-term problems. If I am required to use a diagnosis in order to treat you, we will discuss this prior to this being sent to a third party.
IV. OTHER RIGHTS
You have the right to ask questions about anything that happens during therapy. I am always willing to discuss how and why of what therapy entails, and look at alternatives that might work better for you. Please feel to ask try ideas that you think will be helpful. You can ask me about my training for working with your concerns, and can request that I refer you to someone else if you decide I am not the right therapist for you. You are free to leave therapy at any time, although I strongly recommend providing advance notice so that I can help you end your treatment well.
Individual therapy is $200 per hour session for face to face sessions and $125 using telepsychology (Zoom). The initial appointment is often 90 minutes in length to allow the therapist to formulate a comprehensive case plan. All other sessions are approximately 60 minutes in length. Please pay for each session on the day you receive services. You can expect a statement/receipt for each visit (will be emailed within 24 hours). Please etransfer: email@example.com You may want to submit your receipt for tax purposes (if appropriate) or for reimbursement by your insurance carrier. Every effort will be used to help keep counselling affordable and accessible for all. Please feel free to discuss any concerns relating to finances.
- Missed appointments: If you do not provide 24 hours cancellation notice, or you do not show for an appointment, the fee of $125 still applies. If I can fill your scheduled time spot with another client, you will not be charged.
If your insurance company is being directly billed (MVA), it will be necessary for you to provide written consent.
VI. RISKS AND BENEFITS OF COUNSELLING
Counselling can be both challenging and rewarding. Sometimes being challenged is difficult – you might feel upset during or after a counselling session. Processing new ways of looking at a situation or changing our thinking can also make us feel tired, which is a natural response. If you are having significant distress, please speak openly and honestly about this with Beth. I do not have 24 hour emergency or “on call” coverage. If you experience a psychiatric emergency, you should call 911, connect with a crisis line, or go to the nearest hospital emergency room rather than waiting for me to contact you. (Please see some additional resources at the end of this document).
Rewards can include feeling better about yourself, the situation/difficulties that motivated you to seek support, as well as positive shifts in your thinking. People note they feel hopeful, happy, and more confident after doing the work of therapy. You may experience an increased ability to live more effectively by improving your ability to cope with life pressures by experiencing increased personal insight, and personal empowerment.
VII. YOUR RESPONSIBILITIES AS A THERAPY CLIENT
You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for approximately 60 minutes. You are also welcome to email me if you have questions between sessions (homework, etc). I will respond in a timely manner.
If you’re unhappy with what is happening in therapy, I hope you will speak with me directly and provide an opportunity for me to respond. Truly, I can handle it.
IX. CLIENT CONSENT TO PSYCHOTHERAPY
You are encouraged to keep a copy of this Informed Consent and I will keep a copy on your file. By signing below, the client agrees that informed consent to counselling, as per described above, is agreed upon and fully understood and discussed (if necessary). Ongoing discussion is always encouraged in order to clarify ongoing or arising questions, concerns, or feedback about consent issues.