CONSENT FOR CLINCAL COUSNELLING TREATMENT
& WRITEN DISCLOSURE FORM
ADULT / CHILD / YOUTH (First & Last Name):
Date of Birth:
LEGAL GUARDIAN (S)
I, _______________________ agree that_________________ has talked to me about informed consent and answered my questions.
I, _______________________ give my informed consent to participate in the clinical counselling as discussed with the clinician. This consent may be withdrawn at any time by telling the counsellor.
Confidentiality and its exceptions
Confidentiality is key to the effectiveness of the counselling process, so the personal information you share in counselling will be kept confidential. Confidentiality continues after the end of the counselling relationship. However, there are some instances (exceptions) when confidentiality will not apply:
A/ If a child is or may be at risk of abuse or neglect, or in need of protection;
B/ If a counsellor believes that you or another person is at clear risk of imminent harm;
C/ For the purposes of complying with a legal order such as a subpoena, or if the disclosure is otherwise required or authorized by law.
Collection, use and disclosure of personal information
I may also disclose information for the purpose of a professional consultation, in which case your identity will remain confidential. For any other purposes not outlined here, you will be requested to sign an additional disclosure form.
Anticipated risk of counselling
I, ____________ understand that counseling may evoke some strong emotions or difficult memories, change in self-awareness and different ways of relating to other.
I, the child/youth agree that:
_____ The clinical counsellor has talked to me about informed consent and has answered my questions about the service. This consent may be withdrawn at any time by telling the counsellor.
_____ I give my informed consent to participate in the clinical counselling service as discussed with the clinical counsellor.
I/ we, as legal guardian (s) of the child or youth named above. I/we agree:
_____ The clinical counsellor has discussed informed consent for child/youth clinical counselling and has answered my/our questions.
_____ I/we give informed consent on behalf of the above named child or youth to participate in the clinical counselling treatment as discussed. This consent may be withdrawn at any time by telling the counsellor.
_____ I/we, as legal guardian (s) give informed consent to participate in the clinical counselling service as discussed with the clinical counsellor and the child/youth. This consent may be withdrawn at any time by telling the counsellor and in which point the counselling will stop.
I/we __________________________agree to cover the cost of clinical counselling ($95 individual/$125family) session in the length of 55 minutes at the end of each session in the form of cash, check, direct/credit card payment. Cost of home and/or collateral visits/phone calls will be discussed and/or charged separately. Cancellation of any session need to be done 24 hours in advance. Multiple missed appointments may result in termination of the service by the clinical counsellor.
The proposed course of treatment
I, Suzana Dujmic MC RCC, adhere to provide a safe and supportive environment where you will feel heard and where you have a choice of receiving counselling in the modality of your preference that may best address your needs and desires. If we have different views about the modality proposed by you anda satisfactory agreement is not made, necessary referrals will be made.
If you have a concern about any aspect of your counselling, you are requested to first address it to myself, Suzana Dujmic, RCC. If you find it to be impossible or unsafe, or if your concern is not resolved through collaborative discussion process, you may contact the Register of the BC Association of Clinical Counsellors at 1-800-909-6303.
Client/child/parent/youth signature: Clinical Counsellor’s signature: