top of page
a large expanse of white sand with a blu

Consent Form

I care most about providing impactful, evidence-based therapy and support as you transform yourself, your life in the ways that matter most to you. I believe it’s imperative to begin our journey together with a well thought out comprehensive agreement between us, so you know where you stand in regards to your rights; how your confidentiality & safety will be protected by me.
 

I value our relationship with you and believe that our working relationship is the foundation of the healing process. I value your privacy, your safety and your feelings and thoughts about my services. I will always do my best to find solutions for you if you are unhappy with what I
provide.

Rights:
  1. You may ask questions on what to expect during the individual or group sessions and should be involved in making decisions about your therapy journey.

  2. You may cease sessions anytime, without any impediment and may return to sessions again (subject to therapist availability).  We always encourage you to discuss with me any ending as a good ending is an important part of good therapy.

  3. I have the right to end sessions with you too, usually because I feel I am no longer able to help you and/or someone else would be better placed to help you.

  4. Right to confidentiality: Your confidentiality will be maintained in accordance with the legal and professional frameworks set out by the BPS, HCPC and Data Protection Act 1998. I am required to keep written records of sessions (see Privacy Policy). Information will not be shared or revealed to any person, agency, or organization without your prior written consent. The only exception to this is when I believe a client to be vulnerable to harm or a risk to themselves or others, or the client indicates someone else is at risk. Then emergency contacts will be made with the family/support system of the client as well as other health care professionals (e.g. GP or Psychiatrist) involved in the client’s wellbeing. Plans will be devised with you in case of a crisis.

  5. You can raise any concerns and speak directly with me about any concerns, and I will do the same with you.

  6. Respect for your time, my time and the time of other clients.  If you cannot attend your session please let me know before 12pm the day prior to your scheduled session to allow for another use of that time.  However, I do understand that from time-to- time last minute problems can arise, please let me know at the earliest opportunity.  In a 20 session period I will not charge for the first two late cancellations (late cancellation is anything after 12pm the day before your session).  After this time late cancellations will be charged at your usual session rate.  Your right to two late cancellation will rest after every 20 sessions.

  7. Invoices and payment links are issued on the day of the session. Please ensure you make payment for your session or charged missed session the same day unless otherwise agreed. Failure to make full agreed payment after an initial reminder may result in the use of all legal means necessary to retrieve the owed amount.

Telehealth Consent:

You may have some or all of your sessions via Telehealth. I use Zoom, Microsoft Teams, Google Meets or Cliniko's inbuilt system.
I understand that Telehealth is a mode of delivering health care services, including psychotherapy, via communication technologies (e.g. Internet or phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a
patient’s health care.

By signing this form, I understand and agree to the following:

1. I have a right to confidentiality with regard to my treatment and related communications via Telehealth under the same laws that protect the confidentiality of my treatment information during in-person psychotherapy. The same mandatory and permissive exceptions to confidentiality outlined above also apply to my Telehealth services.
 

2. I understand that there are risks associated with participating in Telehealth including, but not limited to, the possibility, despite reasonable efforts and safeguards on the part of my therapist, that my psychotherapy sessions and transmission of my treatment information could be disrupted or distorted by technical failures and/or interrupted or accessed by unauthorized persons, and that the electronic storage of my treatment information could be accessed by unauthorized persons.
 

3. I understand that miscommunication between myself and my therapist may occur via Telehealth.
 

4. I understand that there is a risk of being overheard by persons near me and that I am responsible for using a location that is private and free from distractions or intrusions.
 

5. I understand that at the beginning of each Telehealth session my therapist is required to verify my full name and current location.
 

6. I understand that in some instances Telehealth may not be as effective or provide the same results as in-person therapy. I understand that if my therapist believes I would be better served by in-person therapy, my therapist will discuss this with me and refer me to  in-person services as needed. If such services are not possible because of distance or hardship, I will be
referred to other therapists who can provide such services.

 

7. I understand that while Telehealth has been found to be effective in treating a wide range of mental and emotional issues, there is no guarantee that Telehealth is effective for all individuals. Therefore, I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured.
 

8. I understand that some Telehealth platforms allow for video or audio recordings and that neither I nor my therapist may record the sessions without the other party’s written permission.
 

9. I understand that my therapist will make reasonable efforts to ascertain and provide me with emergency resources in my geographic area. I further understand that my therapist may not be able to assist me in an emergency situation. If I require emergency care, I understand that I may proceed to the nearest hospital emergency room for immediate assistance.

*Print and Sign

bottom of page