Confidentiality Form

Confidentiality and Procedural Concerns for Counselling
The counselling that you receive is confidential within the limits of the law and the ethics of my profession. I am a Registered Clinical Counsellor with the B.C. Association of Clinical Counsellors. I do keep written records as a record of our work, for legal purposes, and to aid in your progress. However, they could possibly be subpoena-ed by a court under certain circumstances.

Exceptions to Confidentiality:
I understand that all information is considered confidential and will only be shared outside of this relationship if I have given my written permission. I also understand that in some situations, there are exceptions to this above statement. These exceptions include:

  • Reporting of suspected child abuse or neglect
  • Complying with the requirements of a child protection investigation
  • Responding to a medical emergency
  • Complying with a subpoena
  • Responding to a threat of harm to self or others

If it appears that you are imminently about to harm yourself or someone else, I am ethically and legally obligated to let someone know. More important than the legal obligations, though, are my concerns for your health and safety, and that of those with whom you interact.

Informed consent is agreeing to receive treatment services for the issues you bring forth in the sessions. Do you consent to being an active participant in this process?

Yes

No

IMPORTANT: Procedural Concerns for PHONE and SKYPE Counselling
Due to the nature of these modalities and the potential for sessions to be interrupted with the Skype software or internet connections, it is important to note that you are agreeing to the potential of technical issues. If a technical issue happens, I will contact you as soon as I can to either resume the session or to reschedule the remaining portion of the session. Although rare, there are times I may not even be able to get online since I am currently residing in a country with internet connection that can be unstable. If I am not online within 10 minutes of our scheduled time, you will be given a credit for a session and will contact you at my earliest opportunity to reschedule. Often sessions can be booked quickly as Skype allows a lot more flexibility.

The counselling time we have available is one hour unless otherwise discussed. First sessions (intake sessions) are 75 minutes in order to fill out paper work and gather some history, and answer any questions you may have about counseling.

This includes time for payment and for booking other appointments. Payment is made through online banking (EMAIL MONEY TRANSFERS) or via my website.

Email Money Transfers/ Payment
All clients are required to submit their payment via online banking or via my website using PAYPAL. All that is required for you to do email transfer is that you do online banking and that you know my email address: ( nirvanacounselling@shaw.ca ). Once you login to your online banking and follow the directions to do an email money transfer, you will be asked to establish a secret question that I must answer in order for confirmation that you were sending the money transfer to me.

The question I get clients to use is: What is the color of my car? The answer is SILVER.

I have read and understood the above, and I agree to the issues discussed above.

By typing your name below you agree to all the above information:

Name: Date: