SAMPLE: Psychotherapy Consent Form


Your therapist, Helen Geris, offers psychotherapy services to individuals. Your therapist has obtained a Master’s degree in Counselling Psychology, is a fully insured and regulated member of the College of Registered Psychotherapists of Ontario, and has obtained full membership certification with the Canadian Counselling and Psychotherapy Association.

Please note: Your therapist will also provide you with a Psychotherapy Information Sheet that can provide more details on psychotherapy services.
Your therapist will provide you with either in-person psychotherapy sessions at the Limestone Therapies office, and/or virtual psychotherapy sessions through a secure online video platform called TheraPlatform. Regardless of the method you choose to receive therapy, the process of booking, length of session, fee, and cancellation policy are the same.
Please inform your therapist if you will be outside of Ontario during your virtual psychotherapy session. It is important to ensure that your therapist is licensed to provide psychotherapy services to you in the location where you are receiving them.


Confidentiality

All interactions with Limestone Therapies, including the scheduling of your appointments, your attendance, the content of sessions, and your records are kept confidential and secure in adherence with the Personal Health Information Protection Act (PHIPA). Please note that your information is kept confidential within Limestone Therapies, but may be accessed by the clinic owner through our note-taking software for the purposes of ensuring diligent record-keeping and continuity of client care.

All client records and information discussed during counselling sessions will be kept confidential within Limestone Therapies at all times, except under the following circumstances:


  • Reasonable grounds to believe that there is a risk of imminent harm to you or specifically identified others and/or the abuse of children. 
  • Reasonable grounds to believe that a member of a regulated health profession has sexually abused a patient. 
  • A court order.


Please take into consideration that your therapist meets regularly with a clinical supervisor to ensure continuing professional development. This supervisor will maintain the same level of confidentiality as indicated in this form. If you would like further information regarding this supervision arrangement, feel free to ask your therapist.

If you are using virtual therapy, you can be assured that the virtual therapy platform used is PHIPA compliant and your therapist will be in a secure location during sessions. You are responsible for information security on your computer and in your physical location. You are responsible for creating and maintaining your user name and password and to keep this information secure. Unless you have discussed otherwise with your therapist, we require your agreement that neither party will record the video session beyond taking notes. Doing so is a risk to your own privacy and confidentiality.

It is important for you to be aware that email communication can be relatively easily accessed by unauthorized persons and can thereby compromise the privacy and confidentiality of such communication. Recognizing the possible risks to privacy/confidentiality, do you feel comfortable continuing to use email as a form of communication?

YES    NO


Counselling Records

Although your counselling record remains the property of Limestone Therapies, you have the right to access and correct the personal health information we hold within your record. We keep your client files in a secure location for ten years before they are destroyed. You may also request in writing that your therapist release specific information about your counselling to individuals of your choice. In adherence with the regulations of the College of Registered Psychotherapists of Ontario, clients not satisfied with the way their records have been maintained or shared have a right to make a complaint to the College of Registered Psychotherapists of Ontario.

Emergency Management

It is important for your therapist to know your location when receiving services. If you are receiving virtual services please inform her if you are not at the location identified as your home address.
Please ensure that the emergency contact you have provided to Limestone Therapies is a person living in your town/city who could offer you in-person support if needed. If your current emergency contact does not fulfill these parameters, please inform your therapist.



If I don't hear from you when we are scheduled for an appointment, do I have your consent to call you on the phone number listed on file?

YES    NO


Acknowledgment

By signing this document, you are indicating that you have fully read and understood the information presented on this page. You acknowledge and accept the rights and limitations of confidentiality, and you understand that you have a right to withdraw your consent or discontinue services at any time. You hereby consent to receiving in-person and/or virtual psychotherapy services by Helen Geris.
Should you have any questions or concerns at this time, please bring these up with your therapist before signing this document.


Client’s signature       ________________________              Date       _________________________


Therapist’s signature  _________________________            Date       _________________________