(NOTE: This Page is Formatted the same as our Hard Copy Sheet except for Online Submit Option)
Counselling and Psychological Services
(Authority to give Consent)
In Newfoundland Labrador the current age of majority is nineteen years of age, as stated in the Age of Majority Act, as outlined by the Newfoundland and Labrador Psychology Board. If parents are separated, signed consent will be required by both parents unless court ordered. In cases where parents are together, it is the signing parent’s responsibility to ensure the other parent has been informed, though it is recommended that both sign. In the case of couples or family counselling, all members who will be attending will be required to sign.
Consent for Treatment and Confidentiality
Client name: ______________________________________________
I, _________________________________ hereby consent to receiving psychological treatment for myself or a minor in my care, with the following understandings:
I understand that all information shared with my psychologist is confidential and no information will be released without my written authorization. My file will be stored in a secure location in a locked cabinet or on our Practice Perfect EMR operating system. Paper files will be destroyed seven years after the termination of therapy. In the event that my psychologist is unable to perform his/her duties, an alternate psychologist has been designated to oversee my files.
Verbal consent for limited release of information may be necessary in special circumstances which will be discussed and attained prior to any action taken with my personal information.
I further understand that there are specific and limited exceptions to this confidentiality which include the following:
- When there is risk of imminent danger to myself or to another person, my psychologist is ethically and legally bound to take necessary steps to prevent such danger. This may include contacting relevant authorities even if I do not wish my psychologist to do so.
- When there is a reasonable suspicion that a child or elder or any vulnerable person is being sexually, physically or emotionally/psychologically abused or neglected or is at risk of such abuse, my psychologist is legally required to take steps to protect the person, and to inform the proper authorities.
- In certain circumstances psychologists are required by law to disclose what would otherwise be confidential information, such as when served with a court order.
- You should be advised that, as per the provisions of the Psychologists Act, 2005, your file may be subject to a professional audit by the Newfoundland and Labrador Psychology Board (NLPB) pursuant to the provisions of their Quality Assurance Audit practice. If, in the event that your file was to be selected as part of a review process, the auditor would be a registered psychologist and appointed by the NLPB. Please be aware that such Quality Assurance practices are random and isolated in nature and are conducted to ensure and promote the high standards of practice within the Psychology profession and confidentiality is of primary consideration.
- A client’s case information may be discussed with other professionals for the purpose of consultation only. In no way will the identity of the client be revealed.
I understand that I am eligible to receive evidence-based treatment in the form of individual/group/family therapy and/or assessment. The type and extent of service that I will receive will be collaboratively determined through discussion with me.
I understand that I am free to discontinue these services at any time without penalty or prejudice and that I am encouraged to discuss either a change in therapist, approach, or a referral to another professional with my therapist to ensure that I receive the best care possible.
I understand that this consent will remain in effect until such a time as I withdraw it via written consent or discontinue services with my therapist by informing them of my intent to do so.
Individual therapy sessions are between 45 and 60 minutes in duration. Session frequency can vary over the treatment period, depending on the specific therapy goal and the progression of treatment.
I agree to inform my therapist 24 hours prior to our appointment time if I need to cancel or change an appointment time. I understand that unexcused no shows or late cancellations (less than 24 hours) will be automatically billed/charged at the total cost of the session booked.
Financial agreement :
I hereby agree to pay all fees relating to services received. I acknowledge that my session fee is $158 per session, unless covered or otherwise specified through EAP or other contractual agreements in place.
Payment is required at the end of each appointment and will be paid directly to my psychologist, who is an independent contractor. I will receive a receipt upon payment.
Aspens & Oaks accepts e-transfers, debit, or cash for services rendered.
Risks and Benefits :
I understand that while psychotherapy may provide significant benefits based on empirical evidence, it may also pose risks. Psychotherapy may elicit uncomfortable thoughts and feelings or may lead to the recollection of troubling memories. I also understand that choosing not to engage in therapeutic treatment may also result in greater discomfort or escalating risks. It has been explained to me that my feedback and communication about the therapy process and impact is crucial in reducing my risk for harm, and my therapist has encouraged me to communicate any concerns or discomforts with them as soon as is feasibly possible in my treatment. I also acknowledge that therapy is most effective when I am comfortable with my therapist and so, should I not feel comfortable or connected to this therapist I will either request a transfer to another individual or make my concerns known in order to best facilitate care for myself.
Rights and Responsibilities:
I have a right to be treated with respect, dignity, and without discrimination regardless my age, gender, mental and physical status, sexual orientation, race, belief system or ethnic background. I can expect from my therapist to make their best effort to conduct therapy as competently as possible. I have a right to ask questions at any time, be informed by my therapist as to their qualifications, areas of specializations and limitations, and the code of ethics which they follow. I have a right to be advised as to the limits of therapeutic service, discuss my treatment with others (including getting a second opinion), and have been informed of the NLPB grievance procedures so that I may file a formal complaint when I am not able to resolve my concerns with my therapist. I understand that I may stop treatment at any time. I understand that I have a right to know what is being recorded about me in therapy notes.
I understand that I am responsible for setting therapeutic goals for my treatment and review them as required. I will cooperate with my therapist in evaluating the treatment process and work toward achieving my self-identified goals, both in session and between sessions.
Client signature (adult): ________________________ Date: ___________________
Parent Signature: _____________________________ Date: ___________________
Parent Signature: _____________________________ Date: __________________
Psychologist Signature: ________________________ Date: ___________________