Psychology Consultation Request Form

Terms and Conditions

This form is used to gather consent for mindfulness psychology consultation with Dr. Sheena Burke. Please read the terms and conditions of the service provided and confirm your consent to proceed. This form contains 2 sections: Terms & Conditions and Personal Information. Please read through and ensure you are happy to proceed. Please read, review and confirm that you agreed to the following Terms and Conditions of the mindfulness psychology service offered by Dr. Sheena Burke.
1. Dr. Sheena Burke offers a mindfulness psychology service to adults and older adolescents. Following an initial review of needs, we may agree a programme that is informed by an integration of my clinical and educational psychology training and experience with mindfulness. Cognitive-behaviour therapy, humanistic, relational and psychodynamic therapeutic principles may inform my psychological consultations. Therapy may also incorporate EMDR (Eye-Movement Desensitsation Reprocessing), a specialist therapeutic approach for working with distressing emotional experiences associated with upsetting memories.
2. Services are available in person and online (often referred to as 'teletherapy').
3. Online services are provided through interactive internet technologies where we are not in the same physical room together.
4. Clients are expected to attend sessions regularly and require a minimum 24 hour notice for cancellation and reschedule. Appointments that are cancelled with less than 24 hours will require full payment.
5. There are both pros and cons to online therapy services: as we are not in the same physical room, clients are expected to ensure they create a safe space where they can engage in the sessions in a confidential and honest manner. Not being in the same physical space, means a lack of access to information that might be available and may result in errors of judgement. A comprehensive assessment of needs is not provided. Online services are provided using a videoconferencing platform that is GDPR and HIPAA compliant.
6. All information provided by clients is held with privacy and confidentiality, abiding by GDPR (2018) requirements. There will be no disclosure of information shared without express permission of the client or as required by law. The limits to confidentiality extend to any concerns of harm/safety to the client or others and such information may be shared with relevant professionals as required by law.
7. Emergency services are not provided. Any immediate concern for your health and safety must be brought to the attention of your GP or local A&E Department.
8. The fee for individual consultations (2024) is €95. This covers 60-90 minute sessions. Payments for services are required in advance and within 24 hours of sessions. Please book and pay through the website: https://www.discoveringmindfulness.ie/book-a-consultation/
9. Details submitted will be deleted from this server in one year or in the event of appoinments not proceeding. Every effort is made to ensure data is held securely and encrypted and please be aware this is limited to the technology functioning as claimed by the softward provider. If you would prefer to share some details in person, please make contact by telephone to support your submission.
I confirm that I have read and understand the terms and conditions, privacy and confidentiality policy and accept these. I understand in checking this box I am giving my full informed consent to the mindfulness psychology consultation service offered by Dr. Sheena Burke. *

Yes
Personal Information

This information is held in compliance with GDPR (2018) regulations.
Name*
Contact (Email/Address)*
Phone Number

Area CodePhone Number
Reason for Consultation Request *
Previous experience of psychological therapy or similar*
Please advise of any significant health concerns for which you are receiving treatment/therapy currently or in the past? *
Have you experienced thoughts or actions of self-harm? past or present*
Has drug (including prescribed) or alcohol use caused you difficulties? past or present*
Sometimes things happen to people that are extremely upsetting - things like being in a life threatening situation like a major disaster, very serious accident or fire; being assaulted, seeing or hearing about something very distressing that has happened to someone you are close to. Have had any things like this happen to you at any time during your life? If yes, please offer brief detail as you can.
What brings you to seek consultation at this time? *
Form of consultation requested*

In personVideoconferencingTelephoneOther
Do you have a key person or support network of friends, families and/or health care professionals? *
I understand that I take responsibility for my self-care during this session and in abiding by the COVID-19 safety protocols of hand hygiene, physical distancing and coughing/sneezing etiquette. *

Yesnot relevant
Any questions/comments at this stage? *
In case of emergency contact: Please provide a name and contact telephone number of someone who I can contact in the event of an emergency during our contract of time together. *
Signature

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Terms and Conditions

Personal Information