Consent Form for Counselling and Limits of Liability and Confidentiality I/we, (the applicant), hereby request and agree to participate in individual counselling at the Toronto Mindfulness Centre, D.B.A Lotus Mindfulness Centre
• I understand that counseling and Counselling requires that I discuss my problems and difficulties ith a counselor, who will endeavor to provide a supportive, empathic environment and listen attentively. He may pay particular attention to my feelings, thought patterns, and ways of interacting in the world and may point these out to me so that I may gain increased understanding and awareness of how events in my life are impacting on me. The Counsellor will not offer advice or solutions to the problems that I am confronting, but will try to assist me to come to the best decisions and solutions for my particular situation.
• I understand that I am free to ask questions about treatment at any time throughout the treatment process.
• I understand that treatment is likely to help but that this cannot be guaranteed in my particular case. If treatment is not effective, I understand that I have the right to be referred to another counselor for further treatment if I wish.
• I understand that talking about my problems and difficulties may be challenging and potentially painful at times, and that I may feel distressed during the sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of Counselling sessions.
• I understand that I can withdraw from treatment at any time and that if I withdraw, another appropriate alternative or referral will be provided if I wish to continue Counselling.
• I understand that by attending and participating in sessions, I am giving my consent for counselling services.
Confidentiality
- I understand that all information regarding my treatment (including all verbal and/or written exchanges) will be kept confidential, except under the following circumstances. In each of these circumstances, my Counsellor will endeavour to notify me of the need to break confidentiality:
- If I indicate that I may be a danger to myself or others;
- In the case of apparent or suspected abuse of a child under 16;
- If a known sexual perpetrator is in close contact with a child under 16;
- If I report sexual abuse on the part of a health care professional;
- If my records are subpoenaed by a court of law;
- If the records of my Counsellor are randomly audited by the professional bodies that the counsellor is a part of, a quality and skill assurance routine.
• I understand that in order to maintain my confidentiality, my Counsellor will not initiate contact with me, in any private or public setting outside of treatment. Rather, I can initiate any contact outside of counselling based on my level of comfort.
• I understand that my consent is required in order for communication regarding treatment with others, including other health care professionals. I understand that this consent can be provided verbally or in writing, but that my Counsellor’s policy is to obtain my written consent whenever possible.
Fees for Service
- I understand that the fee for service is $95 per 45-minute counselling session.
- Payment is due at the end of each session, payable by cash or personal cheque (made out to the order of “Deepak Kashyap”). I will be provided with an electronic receipt for services rendered at the end of each session or as needed.
- In the case of an online session, the payment would be made prior to the session and a deposit receipt is sent to the email address: [email protected]. An electronic receipt would be provided after the deposit is confirmed.
Cancellations and Missed Appointments
• I understand that I am required to give 48 hours notice for appointment cancellations or changes in order to offer my appointment time to another client. I understand that if I cancel an appointment within this 48-hour period, or miss a scheduled appointment, I will be billed for the session.
Contact
• I understand that I can contact my Counsellor, by email at [email protected] or by phone via call or texting at 647.717.0522. Messages will be responded to during business hours.
Special Limits of Online Services and Assumption of Risks:
- Counselling sessions carry both benefits and risks. Counselling sessions can significantly reduce the amount of distress, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these counselling sessions.
- It is the client’s responsibility to make sure they have a stable Internet connection at their end.
- A call disconnected or dropped will not be considered the responsibility of the counsellor or the clinic. The fess won’t be reimbursed.
- The organization does not run a suicide prevention hotline.
- While we use secure and confidential lines, for phone, text, video-chats and emails, the counsellor and the organization cannot be held responsible for confidentiality at your end.Please make sure you use a secure and confidential line and are sitting in a place where you won’t be disturbed.
- The counsellor or the organization cannot guarantee confidentiality at your end and against unethical hacking.
Any dispute, controversy or claim arising out of or relating to this contract including any question regarding its existence, interpretation, validity, breach or termination or the business relationship created by it shall be referred to and finally resolved by arbitration under the Canadian Arbitration Association Arbitration Rules. The place of the arbitration shall be Toronto, Ontario. In the event either Party is required to enforce this Agreement through legal action, then it will be entitled to recover from the other Party all costs incurred thereby, including without limitation, reasonable attorney’s fees.
We appreciate your help in keeping the office schedule running timely and efficiently.
