Counselling Agreement

With regard to the counselling relationship, I offer a personalized approach tailored to each client’s unique and individual needs for both short-term and long-term counselling. I ensure that my clients can connect with their authentic selves in the warm and safe private setting of their homes, and I utilize a strength-based humanistic approach grounded in a holistic biopsychosocial perspective. Together we will discuss their unique experiences, thoughts, and feelings; and, at their discretion, we will develop a plan that will best suit their needs. We will also periodically reevaluate the changes that they have made and develop more accurate plans, as required.

This document contains important information about my professional services and business policies. It is important that you read the following information carefully; one signed copy is for my files, and I will provide an additional copy upon request. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign it or at any time in the future.

Counselling Agreement

With regard to our counselling relationship, I offer a personalized approach tailored to the unique and individual needs of each client in both short-term and long-term counselling. I provide a warm and safe place for my clients to connect with their authentic selves in a private setting and utilize a strength-based humanistic approach grounded in the holistic biopsychosocial perspective. Together we will discuss your unique experiences, thoughts, and feelings; and at your discretion, we will develop a plan that will best suit your needs. We will periodically reevaluate the changes that you have made and develop more accurate plans, as required.

The following are the requirements of counselling. Please check off each one as you read it.

Appointments Checkbox *

Appointments: Individual counselling sessions are 50 minutes in length, and we can most effectively achieve our goal(s) in weekly appointments. Twice a week might be appropriate for a short period based upon individual circumstances.

Lateness Checkbox *

Lateness: If you are 20 minutes late for a session, I will consider the appointment a missed session and charge you. If you are late your appointment will not run into the next client’s time. I also have the right to change my schedule.

Cancellation Checkbox *

Cancellation: 24 hours cancellation is required to avoid being charged for the session.

Contact Checkbox *

Contact: I will attempt to return messages as soon as possible Monday through Friday (except holidays) or within 48 hours at the latest. You can schedule appointments in person or by telephone.

E-counselling Checkbox *

E-counselling: E-counselling involves the use of electronic technology media, which can include telephonic, email, or video-based platforms. The video-based platforms that I use are user friendly, secure, specific-service tailored, and designed applications for e-counselling; they have PIPEDA/PHIPA/HIPAA-compliant security protocols. Telephonic and email platforms are a risk because they are not secure, and texts are not appropriate for this purpose because of the risk of sending them to a wrong number. I cannot ensure the confidentiality of any form of communication through electronic technology media. When E-counselling support requires texting or contact via email to arrange, cancel, or change appointments, I will keep personal information to a minimum to protect your privacy. Please use only your first name and the initial of your last name in the text or email.

Note Checkbox *

Note: Audio or video recordings may be used to aid the counselling process and to gain further understanding of important aspects of the treatment. An informed consent document will be provided on recordings.

If you are feeling in crisis, dial one of the following crisis lines:

911 if this is an emergency
Or the Kamloops Mental Health Emergency Service: 250-377-0088
Or the First Nations Help Line: 1-855-242-3310 (24/7 – 365 days - serves all of Canada)
Or the Trans Life Line (Transgender Suicide Hotline): 1-877-330-6366
Or the BC Interior crisis line: 1-888-353-2273 (24/7 - 365 days)
Or the Crisis line: 310-6789 (no area code required)

Afterward, please contact me to arrange an appointment.

Counselling Agreement Signature *

I agree that I have read and understand the information above.

Counselling Agreement Signed Date *

Consent for Treatment and Statement of Confidentiality

It is important that you know that your counselling sessions are confidential, restricted only by the Limits of Confidentiality outlined below. In addition, I regularly consult with a clinical supervisor, who is bound by confidentiality, in private supervision sessions on case reviews, case discussions, and video/audio tape reviews. I will keep all communications and records related to your counselling confidential and lock them in a secure place for a maximum of 7 years. Any release of information to any other individual or professional agency will require your written consent and be time limited, and you have the right to withdraw consent at any time. Counselling is voluntary, and you may refuse to participate at any time.

Counselling can provide greater self-awareness, insight, and coping. Counselling may require that you consider exploring difficult topics, or memories, and try new behaviours. These experiences can sometimes lead to stronger than usual emotions. The counselling process will help to manage these feelings; however, this requires cooperation between me and you, as well as your willingness to disclose when emotions become difficult to manage.

Clients should be aware that the counselling process poses certain inherent risks. While we work together, additional problems might surface of which you might have been unaware before counselling. Further, counselling might cause changes in relationship patterns and/or unpredicted responses from individuals in the client family system. Counselling is a collaborative process between me and you, it is not prescriptive in nature.

Limits of Confidentiality

The following practices are very important. Please discuss with me any information that you do not understand.

Please check the boxes to acknowledge that you understand the practices.

If you are under the age of 19 and disclose abuse (sexual and/or physical) from a specific person, I must report the abuse to the Ministry of Children and Family Development. *

If you are under the age of 19 and disclose abuse (sexual and/or physical) from a specific person, I must report the abuse to the Ministry of Children and Family Development.

If you are over the age of 19 and disclose abuse (sexual and/or physical) from a specific person who has access to people under the age of 19, I must report the abuse to the Ministry for Children and Family Development. *

If you are over the age of 19 and disclose abuse (sexual and/or physical) from a specific person who has access to people under the age of 19, I must report the abuse to the Ministry for Children and Family Development.

If there is a possibility that you might seriously harm yourself or others, we must take reasonable action, which can include contacting the police. *

If there is a possibility that you might seriously harm yourself or others, we must take reasonable action, which can include contacting the police.

If you are impaired by drugs and/or alcohol and intend to drive, we must report this to the Motor Vehicle Branch and/or the police *

If you are impaired by drugs and/or alcohol and intend to drive, we must report this to the Motor Vehicle Branch and/or the police

In some court actions, your counselling file can be subpoenaed. This is not a frequent occurrence; however, you should be aware of the possibility. *

In some court actions, your counselling file can be subpoenaed. This is not a frequent occurrence; however, you should be aware of the possibility.

Consent

If you wish that I contact other persons or parties to discuss your treatment and coordinate care, please request a Release of Information authorization form from me, and we will discuss any release of information in advance.

Confidentiality Signature *

I agree that I have read and understand my rights to confidentially as explained above.

Confidentiality Signed Date *

Fee Agreement

Services

I provide counselling services to individuals, couples, and families. My clients are of all ages and come from diverse backgrounds with diverse issues.

Individual Counselling: 50 min/hr $120

Couples Counselling: 50 min.: $150. The first session is either 1 hr. ($150) or 1.5 hrs. ($225), depending on the couple’s needs. The second session is an individual session ($120) with each partner, and the third and subsequent sessions as a couple are 1 hr. ($150) or 1.5 hrs. ($225), depending on their needs. In addition, I might recommend that you complete a research-based online questionnaire as part of the assessment process. You will not be charged the fee for completing the questionnaire. If you terminate treatment at any point during the assessment process and resume at a later date, the fee will be added to the next session’s fee.

Family Counselling: 50 min.: $170: Will require individual sessions with each family member ($120 for 50 min/hr) and family sessions ($170 for 50 min., $255 for 1.5 hrs., depending on their needs).

Payments

I am an approved provider with some insurance companies or managed-care companies that I might be able to bill directly for you. You will need to contact your insurance company if you are seeking reimbursement for my services, and we can help you coordinate these benefits.

Payment by cash, cheque or e-transfer is acceptable at the time of the session. A receipt will be provided upon receipt of payment.

Returned cheques will require an additional $50 administration fee.

It is an important benefit to society in general that every person have an opportunity to access counselling support. Therefore, we might respectfully negotiate a sliding scale depending on the circumstances but limit the sessions to be mindful of the need to avoid causing unnecessary distress for the individual. We will reevaluate the fees and circumstances at the eighth session, when we also reevaluate the counselling goals.

Fee Signature *

I agree that I have read and understand the fee structure.

Fee Signed Date *

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