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COUNSELLING CONSENT FORM

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I understand that counselling often involves discussing difficult aspects of life and I may experience feelings like sadness, guilt, anger, frustration, loneliness and helplessness in the course of our work. It is also my understanding that the benefits of counselling include but are not limited to: increased self-awareness, improved interpersonal relationships, a vitalized sense of self, discovery of meaning and purpose in life, solutions to problems, greater ability to express thoughts and emotions, and reduction in feelings of distress.

 

I understand that there are potential risks and benefits associated with any form of counselling, and that in some cases and at some points in the process, I may even feel worse. I may discuss my ongoing experience of counselling and ask about alternative courses of action when I wish. I understand that the consequences of not engaging in counselling are varied and cannot be defined in a general way. 

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I understand that I have the following rights with respect to counselling: 

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(1) I understand that Rebecca J. Webster draws on a wide variety of counselling techniques and methods, and will sometimes suggest exercises based in this varied methodology. I may also be referred to adjunct alternative health practitioners as part of a holistic mind/body approach. This will be explained to me as is appropriate in the process of our work together. I have the right to withhold or withdraw consent at any time to all or part of this without affecting my right to future care or treatment. 

 

(2) The information disclosed by me during the course of my counselling is confidential. However, there are exceptions to confidentiality, including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards a victim; domestic abuse; legal subpoena, mandatory reports. My counsellor has an ethical obligation to report these. In addition, some confidential material may be discussed during practice supervision as is consistent with professional protocols. 

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(3) I understand that I have the right to request copies of session records on request, subject to providing reasonable notice. 

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(4) I have a right to a receipt for counselling services on request, subject to reasonable notice. 

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(5) If I have any questions or feel uncomfortable with the process of counselling, I understand that I have the right to bring this up in conversation with my counsellor or I may ask for a referral to another practitioner if I choose. 

 

I understand that I have the following responsibilities with respect to counselling: 

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(1) I recognize that counselling is a mutual process in which there is a shared responsibility for decision making and action toward healing, growth and realization of potential. My responsibility includes the recognition of my own agency and capacity for choice and the necessity that I be engaged in the creation, development and enactment of all therapeutic processes. 

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(2) I understand that there is a 24-hour cancellation notice requirement for sessions. I agree to be responsible for payment for any scheduled session I do not attend, if I have not given at least 24 hour notice. I understand that this does not apply to emergency situations, in which case I agree to give as much notice as possible. 

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(3) I will notify my counsellor of my prescription medications and any changes in their usage. 

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(4) I agree to share information regarding my mental and physical health as assessed by previous practitioners, including any disagreements I may have with their opinions. 

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(5) I understand that if my counsellor believes that my needs are beyond the scope of their expertise, that I will be provided with a referral to another practitioner. 

 

I have read and understand the information provided above. I hereby consent to counselling treatment. 

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