Consent for Assessment and Treatment & Disclosure of Information

An effective counselling relationship works, in part, because of clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to change. As a client in counselling, you have certain rights that are important for you to know about because this is your counselling, whose goal is your well-being. There are also certain limitations to those rights that you should be aware of. As a counsellor, I have corresponding responsibilities to you. There must be a clear understanding how our relationship will work and what we can expect from one another. Please read and indicate you have reviewed this information and agree to by checking off the appropriate box on the appointment form. I am available to discuss the content of this document in session.

Download this consent form

About Counselling

Counselling is a broad field that varies tremendously based on the approach used, and on the particular relationship between practitioner and client. Generally, it is a collaborative treatment which takes place in a supportive environment and allows you to resolve, transform and integrate mental and emotional challenges or issues, which may be causing suffering or preventing you from living your life to the fullest. As your therapist, I cannot promise that your behaviour or circumstance will change. Although, I can promise to support you and do my very best to understand you and any repeating patterns, as well as to help you clarify what it is that you want for yourself.

In the beginning, we will collaborate to establish clear goals for the outcome of our work together. During this time, I will be able to offer you my initial impressions of how I can support you and which approaches might be useful. Together, we will develop a plan for reaching your goals. Over time, we will define specific areas of focus, identify particular skills and capacities to be developed and/or healed, and implement approaches that can help you develop/heal them. As part of this, I ask that you please keep me informed about your experience. You are invited to ask questions, express concerns and give me feedback on a regular basis—doing so will optimize our therapeutic relationship and ensure that you get the most out of our work together.

I have a honours baccalaureate degree in psychology and a Master of Arts in Counselling Psychology. I am a Registered Psychotherapist Qualifying with the College of Registered Psychotherapists of Ontario (CRPO), which governs psychotherapy services in Ontario, Canada. Under this designation, I am able to work with individuals, couples and families, offering psychotherapy.

My training and work are based on a Client-Centered approach and I often blend the principles of Cognitive-Behavioural Therapy (CBT) which is used to help individuals work with thoughts-feelings-behaviours that are causing them problems. I also utilize different mindfulness techniques and always see my clients from a trauma informed perspective. I will always inform you about what we are doing and why, include you in the decision-making process, and endeavor to answer any questions you may have.

About E-Counselling

Also known as Telepractice, Cyberpsychology, and Online Therapy. E-counselling is providing a psychotherapy service that is not “in person” and is facilitated through the use of technology. Such technology may include, but is not limited to, telephone, email, internet, or video conference.

E-Counselling is subject to all practice and ethical considerations discussed in this document and in the law, rules and regulations governing licensed practice in Ontario. Clients must provide off-line contact information in case of a technology breakdown.

According to mental health licensing statutes, the law protects the privacy of all communications between a client and practitioner. I practice is in compliance with the requirements of HIPPA and PHIPA. E-counselling takes place on a PHIPA compliant platform Doxy.me, or another compliant platform. You will receive a Zoom invitation along with a pre-screen prior to your scheduled appointment.

Client must ensure privacy is maintained on their end during a Zoom counselling session. This would require a private setting where the conversation with a counsellor cannot be overheard by others in the home or office.

If our sessions are via phone, I will call you at the number you provide me with (please note that face-to-face sessions are highly preferable to phone sessions).

Confidentiality

All information provided (verbally, written, and otherwise) during your sessions and as part of the intake process will be kept confidential by me, except under the following circumstances:

• I may disclose limited information to necessary people (intended victim, legal authorities, and so on) without your permission if I have clear evidence that you are a serious imminent risk of physically harming yourself or another person.
• I am mandated to breech confidentiality if I learn of an incident of child or elder abuse by you or anyone else.
• There are also some situations where the court can mandate that I release your records.
• Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.
• If another professional (i.e. doctor, nurse, social worker etc.) is found to be harming you I am mandated to report it to their regulating college.
• I frequently discuss my client’s cases anonymously with my Supervisor, peers and colleagues to enhance my own learning and hold myself accountable to the work we are doing together.

Please let me know if you understood the above limitations and have any further questions.

Supervision

I meet regularly with my Clinical Supervisor, to help ensure accountability and that I am upholding best practices. My Clinical Supervisor is, Carmen Jelly, MACP, RP, OACCPP, who lives in North Bay, Ontario; we meet weekly or bi-weekly online. In these meetings, I frequently discuss my clients’ cases and will likely share details of your case with my supervisor. I will, however, not share any identifying information such as your name, the names of people you discuss, place of work, or any other information that might compromise your right to privacy. If you have questions about what I discuss with my supervisor, please ask me. It is your right to know what I discuss with them and why. If you’re unhappy with what’s happening in therapy, I hope you’ll talk about it with me so that I can respond to your concerns. I will take such criticism seriously, and with care and respect. If you believe that I’ve been unwilling to listen and respond, or that I have behaved unethically, you can contact my Clinical Supervisor at the following:

Clinical Supervisor's Name
Carmen Jelly, MACP, RP, OACCPP
310 Carmichael Dr.
North Bay, ON
705-358-0986
www.newperceptions.ca

Nature of Our Therapeutic Relationship

I can only be your psychotherapist. I cannot have any other role in your life. I cannot, now or ever, be a close friend or socialize with any of my clients. I cannot be a psychotherapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after, the course of therapy. I cannot have a business relationship with any of my clients other than the therapy relationship.

If we happen to meet in public, I will respect your privacy and will not acknowledge you, or in any way disclose the fact that you are my client. However, you are free to acknowledge me (which I will reciprocate if you initiate), and you are also free to disclose the fact that you are my client to people you wish to share that information with.

Minors

If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

Record Keeping

Your personal health information that has been collected is used for your care and treatment and is stored in a safe and secure platform compliant with the College of Registered Psychotherapists of Ontario (CRPO) and also with the Personal Health Information Protection Act (PHIPA). You have the right to access your health information and will be provided copies if you want them. You always have the right to ask questions about the way the privacy of your personal health information is being handled.

Drugs & Alcohol

To receive the most benefit from our sessions, please avoid the use of drugs or alcohol (except for prescribed medication) for 24 hours before your session.

Fees

My fees per session are $97.35 plus applicable taxes (HST - 13%) per 60 minutes, for individuals.

For payment, I accept cash, credit card, or e-transfer. For credit card payments, I can keep your information on file and charge the card on the day of your session. All payments are due in advance of the session.

Scheduling & Cancellation Policy

After an initial session together, we will assess whether our therapeutic relationship is a fit for both of us. Should you decide to continue, you can choose between weekly or bi-weekly sessions. You will be scheduled at the same day and time either weekly or bi-weekly. If I need to change the time of your appointment, I will give you not less than 1 weeks' notice, and I request that you agree to do the same.

I require one weeks' notice to cancel a session without charge. If you cannot make your scheduled appointment and we are able to reschedule your appointment during the same week, you will not be charged a cancellation fee. I make every effort to reschedule in emergency situations, but sometimes there are no available times.

Late Cancellation or Missed Appointment

If an emergency causes you to cancel a session with less than a week's notice (and we do not reschedule in the same week) you will be charged a cancellation fee of one half of your regular session fee.

Missed appointments and cancellations with less than 24-hours' notice, are subject to the full fee.

Likewise, if I cancel your session with less than one weeks' notice (and we do not reschedule in the same week) you will receive 50% off of your next regular session. If I miss or cancel your appointment with less than 24-hours’ notice, your next session is free.

Phone Calls and Communications

I welcome phone calls ( 249-700-5155 ) and emails info@danielaramos.ca. There is no charge for calls of less than 10 minutes.

Emergencies

If you need to contact me between sessions, please leave a message on the dedicated voice mail service at 249-700-5155. Please note that I am not immediately available but will attempt to return your call within 24 hours. If an emergency arises please call 911 or have someone take you to the nearest emergency room for help. Many crises help line are available, please consult me for their contact information.

Email

I am happy to schedule/re-schedule appointments via email. If you would like me to review documents, correspondences, or respond to email that exceeds 10 minutes of time, there is a prorated fee based on your hourly session fee. Please be aware that e-mail, although normally not read or intercepted by a 3rd party, is not necessarily confidential and I cannot guarantee confidentiality of documents sent via e-mail.

Termination of Counselling

Once you begin regular counselling (weekly or biweekly sessions), you of course have the right to terminate therapy any time you wish. However, in some circumstances people feel that they want to stop therapy when they are about to face something that is uncomfortable, yet potentially very fruitful. For this reason, I request at least two sessions notice—one to discuss termination and make a plan for closure, and the second to summarize our work together, plan your next steps, and bring our work together to a successful close.

Last Updated: June 28, 2020