Consent Form – Rebecca Steele

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Consent Form for Counselling Services 

I hereby request and agree to participate in distance counselling from Rebecca Steele, M.A., CCC.

  • I understand that counselling requires that I discuss my problems and difficulties with a counsellor, who will endeavour 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.
  • 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 will be referred for further treatment if I wish.
  • I understand that talking about my problems and difficulties may be difficult and painful at times, and that I may feel distressed during treatment.
  • 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 treatment is provided by Rebecca Steele, M.A., CCC.
  • 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 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 College of Registered Psychotherapists of Ontario or the Ontario College of Social Workers and Social Service Workers.
  • 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 therapy based on my level of comfort. I understand that it may be advisable to not initiate contact in the presence of others in order to maintain my confidentiality.
  • 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.

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, Rebecca Steele, by email at rebecca.steele@insightvillage.ca or by phone at 519-635-3283. Messages will be responded to during business hours.

Checking the boxes below indicates that I have read and understood the contents of this form and that I freely agree to participate in distance counselling.