Bmindful Psychotherapy and Coaching Centre
Sonia Tanguay, M.Ed
Tel: 613.612.0493 | E-mail: | www.bmindful.ca
Informed Consent
Psychotherapy
In psychotherapy clients are helped by talking about personal difficulties they are facing with a psychotherapist, who is a neutral third-party with specialized training to help people with these issues. Psychotherapy is a collaborative process, so we work together to establish and to achieve the therapy goals. You must be actively involved in therapy by, for example, bringing material to discuss in sessions and applying newly learned strategies to situations outside the therapy office. Typically we meet on a weekly or bi-weekly basis. The number of sessions required to experience noticeable improvement varies widely between clients. We will assess your progress throughout the sessions and adjustments may be made as necessary.
Risk and Benefits of Psychotherapy
The large majority of people who complete psychotherapy experience relief from their distress and improved well-being. While you may notice improvements, therapy can elicit difficult memories, thoughts, and emotions and may affect positively or negatively your interpersonal relationships. It is important to realize that psychotherapy is not effective in every case, and some clients will not achieve desired improvements, and a very small number actually get worse. Please let me know if you experience any significant changes in how you are feeling, either negative or positive. This information helps me to adapt the therapy process to best suit your needs.
Supervised practice
Your psychotherapist is supervised by a registered psychologist, Dr. David Smith, C. Psych. At any time you may contact my supervisor to request a meeting. Note that, if warranted, the supervisor or your psychotherapist can initiate a face-to-face meeting. You can reach him at:
Dr. David Smith, C. Psych.
Email:
Telephone: 819.712.3546
Client Records
You are permitted to access to the hard copy of their file at any time. It is recommended that we review your file together in case you have any content-related questions. For record purposes, you are not permitted to remove or destroy contents from the file.
Disclosure of Personal Information
Your psychotherapist can disclose personal information with formal written consent. With your consent, your personal information may be shared to a third party. Personal information may also be shared during supervision for professional consultation.
Confidentiality
What you share with your psychotherapist is private information and will be kept confidential. However, there are some exceptions to the therapist’s duty to maintain confidentiality listed below:
1. If the psychotherapist believes you or another person is at risk of imminent harm.
2. If the psychotherapist learns that a child, elderly, or dependant person is or may be at risk of abuse, neglect, or in need of protection.
3. If there is a case of sexual abuse by a regulated health professional
4. For the purpose of complying with a legal order such as a subpoena, or if the disclosure is authorized by law.
Fees
Payment for services is due as agreed every session. An official receipt will be issued at the time of payment.
Cancellation Policy
I agree that, whenever possible, I will provide 24-hour notice if I need to cancel my appointment. You will be charged for the full session if you miss an appointment without cancellation. I realize that if I do not show up for two consecutive appointments without prior cancellation, this may result in the termination of my services.
Contacting Me
You may confidentially contact me at:
E-mail: ______
Phone number where it is safe to leave me a message: ______
Emergency Contact
Name: ______
Phone number: ______
Relationship: ______
Consent
You may ask questions at any time or in the future about statements in this form.
Your signature below indicates that you have read this statement, you have been given an opportunity to ask questions about the statement, and that you understand what it means.
First Session Date: ______Fee: $130/50 min
Client Signature ______Date: ______
Psychotherapist Signature ______Date: ______
If you wish to have a copy of this document, please ask your therapist for assistance.