INFORMED CONSENT FOR COUNSELLING SERVICES
Counsellor Credentials
I am a Canadian Certified Counsellor (CCC) in good standing with the Canadian Counselling and Psychotherapy Association (CCPA) and hold a Master of Arts Degree in Counselling Psychology. This document outlines the nature of counselling services, professional policies, and your rights and responsibilities as a client, in accordance with the CCPA Standards of Practice.
Please review this document carefully. Your signature indicates informed consent to participate in counselling services under the terms described below.
Nature and Purpose of Counselling
Counselling is a collaborative process intended to support emotional well-being, personal growth, and psychological healing. Services may include assessment, treatment planning, and therapeutic interventions tailored to your goals and needs. Counselling may address thoughts, emotions, behaviours, relationships, and past or present experiences.
You have the right to ask questions at any time, to participate actively in treatment planning, and to withdraw consent or discontinue counselling services at any point.
Confidentiality and Limits to Confidentiality
All counselling services are confidential and conducted in accordance with the CCPA Code of Ethics and Standards of Practice and applicable provincial and federal laws. No information will be disclosed without your written consent, except in the following legally mandated circumstances:
Risk of Serious Harm to Self
If there is reasonable belief of imminent risk of suicide or serious self-harm, confidentiality may be breached to protect your safety. Efforts will be made to collaborate with you and use the least intrusive intervention possible.
Risk of Serious Harm to Others
If there is credible information indicating an imminent risk of serious harm to an identifiable person, I am legally obligated to take steps to protect that person, which may include notifying appropriate authorities and/or the intended individual.
Abuse or Neglect of a Child or Dependent Adult
Disclosure of suspected abuse or neglect of a child or dependent adult must be reported to the appropriate protection authorities, as required by law.
Legal Proceedings and Court Orders
If counselling records are subpoenaed or ordered by a court, disclosure may be required without your consent. Only the minimum information legally required will be released, and you will be informed whenever possible.
Professional Consultation and Supervision
I may consult with other qualified professionals for the purpose of supervision or professional support. Identifying information will be minimized to protect your privacy.
Coordination of Care
Information may be shared with other service providers only with your written consent, specifying the nature and scope of information to be disclosed.
Privacy in Public and Electronic Communication
To protect your confidentiality, I will not acknowledge you in public settings unless you initiate contact.
Email and voicemail are not fully secure forms of communication. Email communication is limited to administrative or scheduling matters only. Personal or clinical content should not be communicated electronically. I aim to respond to messages within 24 business hours.
Benefits and Risks of Counselling
Potential benefits of counselling may include improved emotional regulation, enhanced coping strategies, improved relationships, behavioural change, and increased self-understanding. Counselling may also involve emotional discomfort, including the experience of difficult feelings such as sadness, grief, anger, anxiety, or distress. Outcomes cannot be guaranteed.
Therapeutic Orientation
My approach is integrative and trauma-informed, incorporating evidence-based and relational modalities including, but not limited to:
Attachment-based therapy
Cognitive-behavioural therapy
Eye Movement Desensitization and Reprocessing (EMDR) for which I am professionally trained under EMDRIA standards.
Internal Family Systems (IFS)
Polyvagal Therapy
Narrative Therapy
Treatment approaches are adapted collaboratively based on client needs, preferences, and informed consent.
Fees, Billing, and Cancellations
The standard fee is $165 per 50-minute session or $240 per 80-minute session, unless otherwise agreed upon in writing. Payment is due at the time of service.
A minimum of 48 hours’ notice is required for appointment cancellations or rescheduling. Late cancellations or missed appointments may be charged the full session fee.
Emergencies and Crisis Support
Counselling services are not intended for crisis intervention. In the event of an emergency, please contact 911, attend the nearest emergency department, or contact the Vancouver Crisis Line at 1-800-784-2433.
Professional Accountability
If you have concerns regarding the professional conduct of a Certified Clinical Counsellor, you may contact:
CCPA
Consent
By signing below, you acknowledge that you have read, understood, and agreed to the terms outlined in this informed consent document and that you consent to receive counselling services.
Client Name: _____________________________________
Client Signature: ___________________________________
Date: _____________________