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ADULT 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.
COUNSELLING RELATIONSHIP -
Our goal is for you and your therapist to work together as a team. Your therapist will expect you to be actively involved in the therapeutic process as you work toward your goals. It’s common for your therapist to assign homework in order to maximize the effectiveness of therapy. Your input is valuable to determine what would be the most useful things for you to do between sessions. Your therapist may also correspond by email/phone between sessions for brief updates.
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.
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 -
If you threaten to harm or kill yourself or someone else and your therapist believes your threat to be serious, he/she is ethically bound to warn your family or the person you have threatened. According to the Child Welfare Act, your therapist is ethically and legally bound to report to the appropriate authorities any abuse (physical, sexual, emotional, or neglect) of a child currently under the age of 18 years. This law is designed to protect children from harm, and requires that all persons report confirmed or suspected cases of child abuse to the proper authorities. If you are involved in litigation of any kind and you inform the Court that you are in therapy, you may be waiving your right to keep your records confidential. If the Court subpoenas your therapist or Acuity Counselling and Therapy Services files, then your therapist is obligated to appear and to answer questions.
Communication between a client and a therapist is not considered privileged communication. If you disclose to your therapist that you have done something illegal, he/she is not legally obligated to report this unless it involves child abuse or direct threat to an individual. In the unlikely event that you or your Employee Assistance Program brings charges or legal action against Acuity Counselling and Therapy Services or its staff, then you waive the right to confidentiality of information. On rare occasions, if a client fails to pay their therapy fees in a reasonable length of time, Acuity Counselling and Therapy Services may choose to use a collection agency to pursue the outstanding account. In this case, we would release information relevant only to locating the person (i.e., name, address, phone).
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.
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.
CLIENT FULL NAME
I consent to receiving services
7071 Bayers Road, Suite 320
(in the Starlite Gallery)
Halifax, NS, B3L 2C2
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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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