Client-Therapist Consent To Telephone/Online Treatment Form
All individuals who wish to become a phone client are required to review Our Client-Therapist Treatment form and agree to the following conditions. By filling out and returning the Bayridge Family Center Client – Therapist response form, you indicate that you understand and agree to the terms and conditions stated below:
- You understand that your counselor practices in the province of Ontario Canada and is governed by the laws of this province.
- You agree that you are at least 18 years old.
- Bayridge is not equipped for crisis or emergency situation. Bayridge Family Center will not provide emergency care services of any kind.
- You agree to supply your true full name, address, and phone number and e-mail address on the Client – Therapist. You agree that all of the information you have provided in the ‘Client –Therapist Response Form” is accurate, and that no important information has been deliberately omitted. You understand that if any of this information is inaccurate, this may be a major limitation in our ability to help you.
- While we are hopeful that your work together with your counselor will be helpful to you, Bayridge Family Center cannot guarantee a positive outcome.
- Bayridge Family Center counsellors/therapists reserve the right to choose whether or not to work with you via phone. If, during your work together, your counsellor discovers that you are not, in fact, someone who can benefit from phone therapy, your counsellor will discuss this with you immediately and will suggest that you seek out the services of a therapist in an office in your local area.
- If you are currently taking medication for depression, anxiety, or any psychological or psychiatric problem, your counsellor may ask for your permission to contact your physicians.
- Phone counseling is not the same as face-to-face psychotherapy. There will never be a diagnosis over the phone. Therefore, if, at any point a diagnostic assessment is required you may be required to have a local face-to-face diagnostic assessment.
- Bayridge Family Center cannot be held responsible for phone services that are temporarily out of service.
Confidentiality In General: As counselors in Ontario we protect the confidentiality of the communications and contacts with all clients, including phone clients. Your therapist will only release information about your work to others with your written permission, or if they are required to do so by a court order or legal subpoena.
- Confidentiality Exceptions: According to Ontario law there are three situations where your therapist is required to break the confidentiality that we work so hard to retain and call local law enforcement or social authorities.
- If during your sessions you give any information that would lead your therapist to believe that you may hurt yourself, someone else, or someone may hurt you in any way, your therapist will notify the appropriate authorities to prevent such actions from taking place.
- If during your sessions you give any information that would lead your therapist to believe that there is neglect or abuse of a minor, your therapist will notify the appropriate authorities to prevent such actions from taking place.
- If during your sessions you give any information that would lead your therapist to believe that a regulated health professional has been involved with sexual abuse, your therapist will notify the appropriate authorities to prevent such actions from taking place.
- BAYRIDGE FAMILY CENTER DOES NOT PROVIDE COUNSELLING OR THERAPY FOR ISSUES RELATED TO PEDOPHILIA AND/OR CHILD PORNOGRAPHY (INCLUDING INTERNET)
- Phone Confidentiality: Your counsellor will do everything possible to protect your identity and keep all confidences. However it is at times not possible to guarantee 100% protection of the confidentiality of phone calls if you choose to use a cordless or cell phone during a phone session. At times it is possible for someone with a scanner to possibly hear the conversation. The goal of phone counselling is to help you. If at any time, either you or your counsellor feels that working together is not helpful enough to you, either is free to terminate the relationship.
- There are no other explicit or implicit commitments to the therapeutic relationship.