Child/Teen Contract and Consent
Burden Bearers Counselling Grande Prairie
Counselling Contract
This contract is between BURDEN BEARERS COUNSELLING SOCIETY of Grande Prairie, Alberta (here and after known as “Burden Bearers”) and __________________________________, here and after known as the “Client”.
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First Name
Last Name
As a Christian-based organization, Burden Bearers respects the values and views of others. We provide services to those from all walks of life and belief systems.
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The Client promises to pay the fee for counselling as set out in their Financial Commitment on the Intake Interview Form, or as otherwise approved based on proof of income as stipulated in Burden Bearer's Reduced Fee Financial Policy. Burden Bearers is a non-profit, charitable counselling organization dependent on donations and client fees in return for professional counselling services. Our standard counselling rate based on current operating costs is $140.00 per hour. Third-party EAP billing rate is determined by the EFAP company and Burden Bearers.
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ATTENTION BEAVERLODGE CLIENTS: with regards to payment, please provide a credit card by phone to the Grande Prairie Burden Bearers office. You may choose to pay by e-transfer but we ask for a credit card to be on file.
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Counselling will seek to address issues of the whole person – emotions, thoughts, actions, and spiritual, as the Client directs.
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Typically, most people will come for hourly sessions on a weekly basis. This will be individualized to meet the Client’s specific needs.
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The Counsellor may take notes, during or after the sessions. These are the sole property of the counsellor. Unidentifiable statistical information may be used from the Client file for statistical reporting. We have a team approach here at Burden Bearers and it is a professional expectation that the Counsellor may, at his/her discretion, seek the aid of other Counsellors on staff for consultation and/or supervision in order to better serve the Client’s needs.
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The Counsellors and staff of Burden Bearers are bound by standards of professional, statutory, ethical conduct, and confidentiality at all times. There will be no confidential information divulged to any person or agency outside of the Client’s session without their written permission, except as provided for below.
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There are limitations to professional confidentiality where the Counsellor may be required to contact the appropriate authorities with the required information.
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These limits of confidentiality include: If a person is deemed by the Counsellor to be at a serious/severe risk of harming himself/herself or others
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These limits of confidentiality include: If there is reasonable suspicion of child abuse
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These limits of confidentiality include:;Our records may be subpoenaed by a Court of Law and other legal limitations/requirements not set out herein.
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The Client is not bound to these counselling services. The Client is free to seek other counselling services or discontinue these counselling services at any time. Either the Client or the Counsellor may end the counselling process by giving reasonable notice (more than 24 hours prior to an arranged session.) If requested, the Counsellor will discuss other counselling options.
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The Counsellor will not accept any personal gifts for counselling services.
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If the Client is unable to attend his/her scheduled appointment and notifies the office staff more than 24 hours before the appointment time, there will be no charge. (Cancellations may be made 24 hrs. a day via the office voicemail.) You are free to refuse and/or withdraw from counselling at any time
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Because your appointment requires your therapist to reserve a significant amount of time exclusively for you, it is necessary to charge a half-fee for appointments that are not cancelled at least 24 hours in advance and the full client fee for no-show appointments. exceptions such as bad roads, illnesses and other emergencies will be considered.
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A credit card number will be required upon booking your first appointment and will be charged for any no-show or last minute cancellations as per above.
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Understood, I will provide my credit card information by phone or in person before my first appointment.
Understood, you have my credit card on file already.
Name on Credit Card
First Name
Last Name
If the Client is behind on paying their fees and/or has missed several appointments without sufficient notice, Burden Bearers reserves the right to cancel all remaining appointments until the account is settled. If you are concerned about this, you may talk about it with your Counsellor.
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Please inform the counsellor if you are going to be late for your appointment. Clients who are more than 15 minutes late, may forfeit their appointment. (With pay)
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It is the client's responsibility to call our office for booked phone appointments and we will put you though to the counsellor.
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If the Client requests a reference letter from his/her Counsellor to a third party, there will be a $50.00 fee for this letter, unless otherwise agreed upon with the Counsellor or the Office Manager.
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Today's Date
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I, the Client, have read and understand this contract with Burden Bearers for counselling. I agree to fully participate in this counselling relationship.
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Signature
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Consent for Counselling a Minor
I,
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Parent/Guardian's Name
hereby give my consent for my
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daughter
son
ward
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Child's /Teen's name
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Add another Child
Do not add another Child
I hereby give my consent for my
daughter
son
ward
Child's /Teen's name
Add another Child
Do not add another Child
I hereby give my consent for my
daughter
son
ward
Child's /Teen's name
Add another Child
Do not add another Child
I hereby give my consent for my
daughter
son
ward
Child's /Teen's name
...to receive counselling services at Burden Bearers Counselling Center. I understand that information will remain confidential and will not be releases without a written consent except when it is required by law. This permission can be cancelled at any time by advising Burden Bearers in writing.
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I agree
Date
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Year
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Signature
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Submit
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