Therapy Contract

CLIENT AGREEMENT

This agreement is between Daniela Gallini ( therapist) and :
Client *

First NameLast Name
E-mail *
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
GP details
GP *

First NameLast Name
GP practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
- Frequency and duration of therapy
  
  The duration of the therapeutic process will depend on the type of difficulty or problem the client is facing. Some people prefer to work with an open contract, whereas others prefer to work with a fixed number of sessions followed by a review. In all cases every 6 sessions we will review our work together. This will help us assess if your needs are being met and help carry out any necessary adjustments or establish new aims for the process.
We have agreed to a minimum of how many sessions to begin our work together ?
- Cancellation Policy
  
  Cancellation of sessions with less than 48 hours’ notice will incur the full fee. I will always aim to give as much notice as possible for any holiday, training workshop , conference or illness that might prevent me from being able to meet with you at our agreed time and place. I will always aim to offer an alternative arrangement.
Do you understand the 48 hours cancellation policy ?

YesNo
- Confidentiality
  
  If you have referred yourself then no one apart from Daniela Gallini will know you attended and what we have discussed .
  
  As part of my professional standards , from time to time I may need to share and discuss some of the information in our sessions with a qualified supervisor , always under a strict confidential framework. Your identity will always be kept anonymous.
  
  Exceptions
  
  In certain circumstances , Daniela may have to make exceptions to the general rules of confidentiality :
  
  1. If Daniela thinks there might be serious risk of harm to ourselves or others.
  
  2. When Daniela can not contact you but thinks you are in danger.
  
  3. Where there is a legal requirement to disclose information. For example, if information has been ordered by a court or because the law requires it.
  
  In all scenarios Daniela will try to talk this through with you beforehand.
- Notes and record keeping
  
  Our policy is to keep all notes anonymous. The information I store includes:
  
  - Your signed contract with details such as your name , date of birth, address etc.
  
  - Confidential and anonymous case notes (describing main focus of the session with any important information )You can request in writing to see information held on you.
  
  -All information will be recorded and processed in line with the requirements of the GDPR (UK)(EU) and the Data Protection Act 2018. Communication in between sessions In order to maintain therapeutic boundaries if you want to communicate with me in between sessions please do it via email to danielatherpay1@outlook.com and only for logistical purposes such as canceling a session , rescheduling the time for your appointment Influence of alcohol or substances Sessions will not take place if the client is under the influence of any misuse of alcohol or substances.
  
  PLEASE READ THIS CONTRACT CAREFULLY Check what we have agreed today and I will be happy to discuss any doubts you might have before signing.
I agree and understand to all of the above, Signature*

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CLIENT AGREEMENT