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ADOLESCENT CONSENT FOR SERVICES AND CONFIDENTIALITY AGREEMENT
Thank you for giving us the opportunity to help you reach your goals. Please read the following pages carefully, and ask about anything that is unclear. Clicking the button at the end will indicate that you have read and understood the information, and that you agree to the terms of service and payment.
THERAPIST QUALIFICATIONS -
All therapists at Acuity Counselling and Therapy Services Inc. are registered and licensed with their governing bodies. Their practices are guided by the Ethical Codes of those bodies. Acuity’s therapists are members of professional associations and have specialized training in several areas. They also participate in ongoing professional development and consult regularly with colleagues and other therapists, attend conferences and seminars to discuss cases confidentially and anonymously, and ensure their skills are current.
SESSION FORMAT -
Sessions are normally 50 minutes long and are usually face-to-face but under certain circumstances your therapist may be able to hold sessions over the phone or video upon request. During your therapy session you can expect your therapist to listen to your concerns, allow you to express your feelings and help you identify your strengths and resources. Your therapist can also help you navigate the thoughts, feelings or behaviors, that may interfere with you meeting your goals and help you set goals and develop plans for managing or overcoming obstacles to your mental health. Your therapist may also provide relevant information, verbally, via email or written documents and conduct formal and informal assessments to measure your progress and motivation. He/she may suggest some reading or writing assignment to help you gain insight into your concern.
YOUR RIGHTS -
You have the right to ask questions about your therapist’s treatment methods so you can make informed decisions about what methods are most suitable for you. In starting therapy, you begin a goal-focused process that has a beginning, middle, and end. You have the right to stop therapy anytime. It is recommended that stopping therapy be planned for and discussed with the therapist. If this should happen, we would appreciate your feedback about the reason for stopping. Your therapist may be able to suggest alternative resources. You have the right to ask for a referral if you feel you are not benefiting from therapy.
COUNSELLING RELATIONSHIP -
The purpose of meeting with a therapist is to get help with things that you may be struggling with in your life. You may be here because you want to talk to a therapist about one specific issue that is bothering you, or multiple concerns that are negatively affecting your life. Sometimes you will find yourself here because your parent, guardian, doctor or teacher had concerns about you. When you and your therapist meet, you will talk together. Your therapist will ask questions, listen to you, and together you will come with ideas for dealing with the issues that bother you. It is important that you feel comfortable talking to your therapist about whatever you want. Sometimes discussions will include topics that you do not want your parents or guardian to know about. Most people feel more at ease when they know that the information they tell the therapist will be kept private. Respecting your privacy and maintaining confidentiality is an important and necessary part of productive therapy.
What you disclose during the therapy sessions is kept in strict confidence. All session notes are kept in locked filing cabinets and only therapists and our director of operations have access to them. Digital files and electronic client data are kept in secure password safe locations. There are, however, limitations to the full extent that emails and electronic mediums can be completely confidential and clients are advised to be aware of this when using these means of communication. If you and your therapist determine that it would be helpful to share information about your therapy with someone else (e.g., your physician), then your therapist will ask you to sign a form that gives Acuity Counselling and Therapy Services permission to release and/or request information. Couples who share information in individual sessions are able to request that such information is kept confidential as long as it does not jeopardize the integrity of ongoing couple therapy. Please note that details of your therapy sessions may be discussed within a clinical consultation setting between therapists at Acuity Counselling and Therapy Services. Those details are discussed anonymously and do not include any identifying information such as name, address or financial information. Services that are being paid for by third party agencies such as insurance providers and EAPs may require sharing information related to billing only.
EXCEPTIONS TO CONFIDENTIALITY -
In some situations, therapists are required, either by law or by the ethical guidelines of their profession, to disclose information whether or not they have your permission. If you tell your therapist that you plan to cause serious harm or death to yourself or someone else, and the therapist believes you have intent and ability to carry out this threat then your therapist must inform a parent or guardian (and the other person, if the threat is against them.) Your therapist must make sure that you and the other person are protected from harm. If you are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person, your therapist will use his or her professional judgment to decide whether a parent or guardian should be informed. If you are under 16 and you tell your therapist you are being abused, physically, sexually, or emotionally, or that you have been abused in the past, then your therapist is required by law to report the abuse to the Nova Scotia Department of Community Services. If you are involved in a court case and a request is made for information about your counseling or therapy, your therapist will not disclose information without your written agreement unless the court (a Judge) requires the therapist to do so. If this situation arises, your therapist will inform you that this is happening.
COMMUNICATING WITH YOUR PARENTS OR GUARDIANS -
Except for those situations such as those mentioned above, your therapist will not tell your parent or guardian specific things you share in therapy sessions. This includes activities and behavior that your parent/guardian would not approve of – or would be upset by – but that do not put you at risk of serious and immediate harm. However, if your risk-taking behavior becomes more serious, and your therapist determines that you are in danger then he/she will communicate this information to your parent/guardian. Even if the therapist has agreed to keep information confidential to not tell your parent/guardian, the therapist may believe that is it important for them to be aware of what is going on in your life. In these situations, your therapist will encourage you to tell your parent/guardian and will help you find the best way to tell them. Also, when meeting your with parents, your therapist may sometimes describe problems in general terms, without using specifics in order to help them know how to be more helpful to you. You should also know that by law in Nova Scotia your parent/guardian may have the right to see any written records kept about your sessions. It is extremely rare that a parent/guardian would ever request to look at these records and their permission for confidentiality will be requested.
COMMUNICATING WITH OTHER ADULTS
Your therapist will not share any information with your school unless he/she has your permission and permission from your parent/guardian. Sometimes your therapist may request to speak to someone at your school; it may be helpful in some situations for your therapist to give suggestions to your teacher or counselor at school. If your therapist wants to contact your school, or if someone at your school wants to contact the therapist, this will be discussed with you and your therapist will ask for your written permission. In the unlikely event that your therapist does not have your permission, but both the therapist and your parent/guardian believe that it is very important for the therapist to be able to share certain information with someone at your school, your therapist will use their professional judgment to decide whether to share any personal information. Your therapist will tell you if he/she felt it necessary to do this.
Sometimes your doctor and therapist may need to work together if, for example, you need to take medication in addition to seeing a therapist. Your therapist will get your written permission and permission from your parent/guardian in advance to share information with your doctor. The only time your therapist will share information with your doctor even if your permission is not given, is if you are doing something that puts you at risk for serious and immediate physical/medical harm.
In some circumstances, your therapist may need to speak to his/her colleagues at Acuity Counselling And Therapy Services to determine what is the most appropriate course of action to take or how best to help you, for example, if one or another of the above situations were to arise. In those situations, your therapist would protect your privacy by discussing only the circumstances and keeping confidential any personal information about you.
Selecting 'Yes' below indicates that you have reviewed the policies described above and you understand the limits to confidentiality. If you have any questions as we progress with therapy, you can ask your therapist at any time.
PARENT AGREEMENT FOR ADOLESCENT TREATMENT & CONFIDENTIALITY
In Nova Scotia, any person under the age of 19 is considered a minor. The competence of minors to provide informed consent to services is not assumed and parental/guardian approval is usually needed. A parent/guardian has a right to know all aspects about those services, but as children grow and are more able to understand and make their own choices, they assume legal rights. An individual may be considered a mature minor if it is judged that they can understand and appreciate the nature and consequences of their decision and its alternatives. In such cases, the details of issues they discuss may be treated as confidential. That being said, parents/guardians do have the right to general information, including how therapy is going. Although there is no set age limit for an individual to be considered competent to give consent, mature minor status is typically considered during adolescence and on a case-by-case basis. In all circumstances with young people, even children, therapy needs to be a safe environment where clients of every age are able to talk freely. At Acuity Counselling and Therapy Services we implement policies and try to balance a parent’s right to know about their child’s progress in therapy with the child’s need for confidentiality in order to foster a therapeutic alliance.
Parents will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed. You will be informed about situations that could endanger your adolescent or child. The decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment and may sometimes be made in confidential consultations with his/her colleague at Acuity Counselling and Therapy Services. Although you have the legal right to request written records/session notes because your adolescent or child is a minor, you understand that these records will be limited in nature to respect the confidentiality of your adolescent or child for the benefit of his/her treatment.
METHOD OF PAYMENT -
Acuity Counselling and Therapy Services accepts payment by credit card, debit or cash before the start of each session. Please note that we require a valid credit card on file prior to booking appointments. It is our experience that clients prefer to deal with payments prior to entering their session. If your therapy is covered by an insurance policy, you will need to pay the fee and then seek reimbursement from your insurance provider.
Please note that private therapy services are not covered under Nova Scotia’s MSI program.
INSURANCE DISCLAIMER -
Acuity Counselling and Therapy Services is always expanding the agencies we panel with. Please note, that most private insurance companies (Sunlife, Great West Life, Manulife, Des Jardins, etc.) do not offer direct billing services but will reimburse you once you submit your paid receipt. Clients whose coverage is with Blue Cross and have plans that permit direct billing can provide their Blue Cross card to our administrative staff for direct billing, but will be responsible for paying the co-pay portion of the fee. It is the client's responsibility to ensure their insurance policy is active. If your insurance plan coverage becomes depleted, it is your responsibility to secure an alternate method of payment for services. Acuity Counselling and Therapy Services is paneled with multiple Employee Assistance Programs (EAPs) and government agencies (Veteran Affairs, RCMP, NIHB, Community Services, Disability Support Program, etc.). If you are referred from one, you will not be billed for services as per the agreement with this provider. Acuity Counselling and Therapy Services confirms your eligibility for EAP and agency services on a monthly basis. If you have a lapse in coverage through EAP or government agency, our administrative assistant will contact you and inform you of the lapse so that you can contact your case manager. In circumstances where problems are encountered in receiving payment for services rendered, your sessions will be put on hold until payment for outstanding invoices is received.
FEES FOR OTHER SERVICES -
In addition to therapy and assessment sessions, we bill for other professional services that you ask us to provide such as phone calls and emails which are pertinent to your therapy, reports and letters, case conferences, meeting and school/home visits as well as travel time. Normally we do not participate in legal proceedings associated with work we do in therapy because it significantly interferes with creating a safe and confidential environment and a secure therapeutic relationship. If you become involved in legal proceedings that require our participation, you will be expected to pay for our professional time even if we are called to testify by another party. Because of the difficulty of involvement in court matters, we charge for preparation and attendance at any legal proceeding. As with everything we do together in therapy and counseling, we will discuss these matters should they arise and try to resolve them to your satisfaction.
CANCELLATIONS AND MISSED SESSIONS -
If you need to re-schedule an appointment, please phone ahead (902-406-3400), giving at least 48 hours notice. If you miss an appointment without notice, or cancel a session with less than 48 hours notice, you will be charged the full fee for that session. If service fees are being paid by an Employee Assistance Program or insurance company, missed session fees are not usually covered and will be your responsibility to pay for. We understand that sometimes there are unforeseen circumstances, such as illness or inclement weather, which may prevent clients from attending their session. You will not be charged for sessions that are cancelled due to inclement weather or other unforeseen events. If your therapist cancels your appointment, you will not be charged for that session.
By selecting 'Yes' below you understand that at least 48 hour notice needs to be given to change or cancel an appointment. You agree to participate in the therapy process with Acuity Counselling and Therapy Services Inc. and that the therapy process is collaborative. You understand that information about you is confidential and understand the limits to confidentiality. You agree to pay for missed sessions and short-notice cancellations plus any applicable fees, and understand that your credit card if on file will be charged for the service fee plus any additional fees. You have read, understand and agree to the information on this form.
ADOLESCENT FULL NAME
I consent to receive services
PARENT FULL NAME
I consent to my child/adolescent receiving services
3400 Dutch Village Road, Suite 101
Halifax, NS, B3N 0E7
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HOURS OF OPERATION
Our therapists have varying schedules. We operate Monday to Friday from 9am to 7pm. We offer daytime and evening appointments.
The Nova Scotia Board of Examiners in Psychology
Nova Scotia College of Social Workers
cuity Counselling and Therapy Services Inc. All rights reserved.
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