Supporting Transformation,
Adolescence to Adulthood
Jennifer S. Kirk, Counselling & Consulting
MA, OACCPP, 3916-G
39 Alvin Avenue,
Toronto, ON, M4T 2A7
*647-632-1656
Consent to Therapeutic Counselling
And Use of Personal Information Form
Counselling
Therapeutic counselling provides a safe space and opportunity for you to explore ways behaviours, relationships, feelings, or thoughts, which trouble you and cause difficulty in your life. Therapeutic counselling is also a legitimate source of support in a crisis or during a difficult time. The process can bring deeper personal insight and awareness, better ways of understanding and coping with problems, and improve relationships. Examining difficult experiences and topics in your life can create some emotional discomfort as you process your reflections at deeper levels. While this may be more intense than usual for a period of time, it will ultimately allow you to integrate self-knowledge in more meaningful ways in order to allow you to transform into your preferred ways of being, based on your identified goals for growth. As such, it is important to attend to pacing in counselling, so that you are able to process reflections and desires for the future in smaller, more manageable pieces. It is your right as a client to adjust the pace at which different elements are explored so that you do not leave the office feeling vulnerable. We will work on this together and you are encouraged to be forthcoming about your feedback on the pacing from session to session to ensure the best quality of service for yourself. I look forward to assisting you in reaching your desired goals.
Collection, use and disclosure of personal information
Personal information gathered in the course of therapeutic counselling will be used in accordance with the purposes outlined in the paragraph above and will not be disclosed except as follows:
Confidentiality and its exceptions
Confidentiality is key to the effectiveness of the therapeutic counselling process, so the personal information you share in sessions will be kept confidential. Confidentiality continues after the end of the therapeutic counsellingrelationship. There are, however, some exceptions to the Counsellor’s duty of confidentiality, in particular:
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 purpose of complying with a legal order such as a subpoena, or if the disclosure isotherwise required or authorized by law.
d.If the client has consented for the Counsellor to share information with an identified party, including other professionals for the purpose of service planning
e. Clinical Consult/supervision of the Counsellor’s work, for the purposes of ensuring the best service to the client (* names are not shared in these structured meetings unless the client has given consent to do so).
If you have any questions or concerns about how the Counsellor’s personal information policies and procedures it is your right to ask and it is my wish to be transparent about these.
Reviews, referrals and ending
In psychotherapy, it is your right at any time to:
a.have a review of your progress and of any of the topics in this form;
b.be provided with a referral to another counsellor or health professional;
c.withdraw consent for the collection, use, or disclosure of your personal information, except where precluded by law;
d.end the therapeutic counselling relationship by so advising the counsellor
e.access or obtain a copy of the information in your counselling records, subject to legalrequirements.
Your right of access to or to obtain a copy of your personal information continues after the end of the therapeutic counsellingrelationship.
Concerns
In order to protect the privacy of the client, if the therapist and client see each other in public, the therapist will not acknowledge the client unless client acknowledges therapist first.
If you have a concern about any aspect of your counselling, you are requested to first address it with Jennifer S. Kirk. If this is impossible or unsafe, or if your concern is not resolved through discussion, you may contact the Ontario Association of Consultants, Counsellors ,Psychometrists and Psychotherapists (416-298-7333).
Signature
My signature below confirms that I have read the above, had an opportunity to discuss it with theCounsellor, and had my questions answered to my satisfaction.
Name of Client:______
Signature of Client:______
Date Signed:______
Consent To Clinical Counselling And Use Of Personal Information Practice Standards and Model Language Approved Board of Directors March 19th, 2005. (Adapted)