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I would ask that you read through and sign my consent to treatment and confidentiality agreement form prior to commencing treatment. It contains important information regarding expectations for therapy, the confidentiality agreement and limits of confidentiality. It also clarifies any financial enquiries you might have about the process.
Consent to Treatment
1. Confidentiality:Any information you discuss with me on the phone or in person is confidential. However, if I have concerns about your personal safety or the safety of others I am legally obliged to share information with a third party. This includes situations in which:o You tell me you plan to cause serious harm or death to yourself, and I believe you have the intent and ability to carry out this threat in the very near future, I must take any necessary steps to assure your safety.o If you present a risk to others (including the abuse of others), I must take steps to assure their safety. If you tell me you plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future then I must report to the appropriate authorities and the person potentially at risk.o If I am informed of abuse to children under the age of 16, I must by law report to the appropriate authorities. This includes children who have been witness to family violence.o Information must be released as required by law in the case I am subpoenaed (legally ordered)
If you elect to communicate with me by email or text at some point in our work together, please be aware that they are not confidential. Therefore, please do not email or text content related to your therapy sessions. I prefer using email or text only to schedule or modify appointments. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider.
2. Record keepingCounselling notes are so that it is possible to keep a record of your words, the issues discussed, ideas that have been developed, your contact details. You can discuss your counselling notes at any time with me and you are welcome to take a copy of these notes home with you. The notes are for my use only. I keep a copy of these notes in a secured filing cabinet at my office and they are considered confidential. If we need to discuss any of these details with another professional agency, I will seek and gain written permission from you before doing so.
3. Services that are not provided:I do not provide court assessments, parenting capacity assessments, custody-access reports or give recommendations or opinions in custody-access matters. I also do not provide DSM diagnosis or diagnostic clarification. If you are looking for those services, I may be able to assist you in finding the right service for you.
4. In case of emergency:If you are experiencing an emergency or if you believe that you cannot keep yourself safe, please call 911, or go to the nearest hospital emergency room for assistance. There is also a free provincial Mental Health Crisis Line in Nova Scotia that is available 24/7 at 1-888-429-8167 that is answered by professional mental health clinicians.
5. Fees & payment• Sessions are 60 minutes in length which includes time at the end for payment. • Payment is due on the day of your appointment.• Hourly fee is $175.00 (This recommended fee is based on a comparison of other mental health professionals in Nova Scotia providing counselling and mental health services)• Payment must be made by cash, cheque or e-transfer at the end of each session. Any NSF charges/fees are your responsibility.• Receipts of payment will be provided if requested.• If the cost of your counselling is being covered by a third party other than Blue Cross, you are expected to pay the fee immediately following your session via the above noted payment methods. I am happy to provide you with a note and/or receipt if needed for reimbursement from your third party. Please note, I am an approved provider for direct billing with Blue Cross, therefore I can do so following your sessions. If the full amount of the session is not covered however, you can pay the remaining fee via the above payment methods.
6. Missed appointment and cancellations:There are some practical responsibilities that support the counseling process. It is expected that you:• Ensure that you are on time for appointments as sessions cannot be extended to accommodate late starts.• Please try to give at least 24 hours notice of cancellations• ‘No shows’ will be billed for the full cost of the session.• If your counselling fees are covered directly by a third party, please note they will not pay for missed or cancelled appointments and you will be personally responsible for the cost.• Fees for missed appointments are due within one week of the missed appointment.
Client Consent to therapyI have read this document, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I understand the limits to confidentiality required by law. I agree to undertake therapy with June Burke-MacDonald RSW, MSW. I know I can end therapy at any time I wish and that I can refuse any recommendations or suggestions made by Ms. Burke-MacDonald.
Signed:____________________________ Witness:_____________________________
Date: _____________________________
1. Confidentiality:Any information you discuss with me on the phone or in person is confidential. However, if I have concerns about your personal safety or the safety of others I am legally obliged to share information with a third party. This includes situations in which:o You tell me you plan to cause serious harm or death to yourself, and I believe you have the intent and ability to carry out this threat in the very near future, I must take any necessary steps to assure your safety.o If you present a risk to others (including the abuse of others), I must take steps to assure their safety. If you tell me you plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future then I must report to the appropriate authorities and the person potentially at risk.o If I am informed of abuse to children under the age of 16, I must by law report to the appropriate authorities. This includes children who have been witness to family violence.o Information must be released as required by law in the case I am subpoenaed (legally ordered)
If you elect to communicate with me by email or text at some point in our work together, please be aware that they are not confidential. Therefore, please do not email or text content related to your therapy sessions. I prefer using email or text only to schedule or modify appointments. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider.
2. Record keepingCounselling notes are so that it is possible to keep a record of your words, the issues discussed, ideas that have been developed, your contact details. You can discuss your counselling notes at any time with me and you are welcome to take a copy of these notes home with you. The notes are for my use only. I keep a copy of these notes in a secured filing cabinet at my office and they are considered confidential. If we need to discuss any of these details with another professional agency, I will seek and gain written permission from you before doing so.
3. Services that are not provided:I do not provide court assessments, parenting capacity assessments, custody-access reports or give recommendations or opinions in custody-access matters. I also do not provide DSM diagnosis or diagnostic clarification. If you are looking for those services, I may be able to assist you in finding the right service for you.
4. In case of emergency:If you are experiencing an emergency or if you believe that you cannot keep yourself safe, please call 911, or go to the nearest hospital emergency room for assistance. There is also a free provincial Mental Health Crisis Line in Nova Scotia that is available 24/7 at 1-888-429-8167 that is answered by professional mental health clinicians.
5. Fees & payment• Sessions are 60 minutes in length which includes time at the end for payment. • Payment is due on the day of your appointment.• Hourly fee is $175.00 (This recommended fee is based on a comparison of other mental health professionals in Nova Scotia providing counselling and mental health services)• Payment must be made by cash, cheque or e-transfer at the end of each session. Any NSF charges/fees are your responsibility.• Receipts of payment will be provided if requested.• If the cost of your counselling is being covered by a third party other than Blue Cross, you are expected to pay the fee immediately following your session via the above noted payment methods. I am happy to provide you with a note and/or receipt if needed for reimbursement from your third party. Please note, I am an approved provider for direct billing with Blue Cross, therefore I can do so following your sessions. If the full amount of the session is not covered however, you can pay the remaining fee via the above payment methods.
6. Missed appointment and cancellations:There are some practical responsibilities that support the counseling process. It is expected that you:• Ensure that you are on time for appointments as sessions cannot be extended to accommodate late starts.• Please try to give at least 24 hours notice of cancellations• ‘No shows’ will be billed for the full cost of the session.• If your counselling fees are covered directly by a third party, please note they will not pay for missed or cancelled appointments and you will be personally responsible for the cost.• Fees for missed appointments are due within one week of the missed appointment.
Client Consent to therapyI have read this document, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I understand the limits to confidentiality required by law. I agree to undertake therapy with June Burke-MacDonald RSW, MSW. I know I can end therapy at any time I wish and that I can refuse any recommendations or suggestions made by Ms. Burke-MacDonald.
Signed:____________________________ Witness:_____________________________
Date: _____________________________