Informed Consent Form

Welcome to Sanctuary by Solace. Please take a few minutes to read through this informed consent form so that you can be fully informed about the therapy sessions you will be engaging in. 

Should there be any questions that you would like to ask, please contact out clinic coordinator at +60 11 2675 4686. 

THE MENTAL HEALTH SCREENING PROCESS

Mental health screening is designed to provide an overview of my emotional wellbeing and to identify potential areas of concern. It may assist in determining whether further evaluation or support would be beneficial.

• I am aware that this screening is a preliminary tool, conducted by the trained admissions team, and does not constitute a full psychological assessment, diagnosis, or treatment.
• I understand that the screening may involve answering questionnaires or discussing personal matters, which could bring up uncomfortable feelings such as stress, sadness, or anxiety.
• I acknowledge that the results of this screening are intended for informational purposes only and that a more comprehensive assessment may be recommended should concerns be identified.
• I understand that I may ask questions regarding the screening procedures whenever they arise.

THE THERAPY PROCESS

Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.

• I am aware that therapy may involve discussing unpleasant aspects of my life and that I may experience uncomfortable feelings such as anxiety and sadness.
• I understand that in order for the therapy to be most successful, I will have to work on matters that are discussed during the sessions as well as on my own, between sessions.
• I understand that I may discuss any questions with regards to the therapist's procedures whenever they arise.

CONSENT FOR TREATMENT. I authorize and request that my therapist carry out psychological assessment, treatment and/or diagnostic procedures, during the course of my therapy whenever it is advisable.

• I understand that the purpose of these procedures will be explained to me upon my request and that they are subject to my agreement.
• I understand that my therapist can make no guarantees about the outcome of my treatment.

LENGTH OF TREATMENT. I understand that therapy length varies with the nature of my issue, thus making predictions of the treatment length is challenging. Under ideal circumstances, the therapist and I will agree on ending therapy.

• If I choose to end therapy earlier, I am aware that having a final session is recommended to discuss ending therapy.
• I also understand in some cases individual therapy may be limited, and alternative options, such as group therapy, may be suggested.

CONFIDENTIALITY. I understand that my relationship with my therapist is confidential, and in exception of certain circumstances, information will only be released to others with my written consent.

• In special circumstances where I pose a danger to myself and/or others or when there is indication that a child, disabled person or elderly faces abuse and/or neglect, I understand that my therapist may need to share my information without my consent.
• If group therapy is utilized as part of my treatment, I understand that discussions should not be discussed outside of therapy sessions.
• I am aware that my therapist may disclose relevant information of myself for the purpose of supervision, legal defence in the event of a complaint or a lawsuit, or if subpoenaed in legal proceedings.
• I understand that there will be no form of recording of the online psychotherapy by either parties. All information disclosed within sessions are confidential and may not be disclosed to anyone without any written authorisation unless in special cases where disclosures are permitted and/or required by law.
• I understand that my relationship with my therapist is confidential, and in exception of certain circumstances, information will only be released to others with my written consent. In special circumstances where I pose a danger to myself and/or others or when there is indication that a child, disabled person or elderly faces abuse and/or neglect, I understand that my therapist may need to share my information without my consent.

ONLINE THERAPY. Online therapy provides access to psychological support via secure video or phone platforms.

• I am aware that online sessions may face limitations such as technical issues, reduced non-verbal cues, and privacy risks.
• I understand that it is my responsibility to attend sessions from a secure and private location. I acknowledge that Sanctuary by Solace and my therapist are not liable if others overhear or access the session on my end.
• I am aware that while reasonable measures will be taken to ensure confidentiality, no online platform is completely risk-free.
• I understand that if technical disruptions occur, my therapist will attempt to reconnect or, if necessary, continue by phone or reschedule.

APPOINTMENTS AND CANCELLATIONS. I understand that sessions are typically once per week, lasting 50 minutes unless otherwise agreed upon myself and my therapist.

• I also understand that each session will begin and end promptly, and if I am late, the therapist may not be able to extend the session beyond the scheduled time and that I will be charged the full amount for the session.
• I am fully aware that full payment is required to confirm the session. I understand that my session will be cancelled if no payment is received within 24 hours of the time of booking.
• I am fully aware that a 24-hour notice must be given to reschedule or cancel any appointment. If I miss or cancel any appointments with less than 24-hours' notice, I understand that I will be charged for the full 50-minute session.

 

Note: Sanctuary reserves the right to terminate services if a client cancels or reschedules more than three consecutive appointments. This policy ensures the availability of sessions for other clients and maintains the integrity of our therapeutic process.

CASE CLOSURE. I understand that my file may be closed if I do not have any contact with my therapist in 90 days. I am also aware that I am free to contact the center if I desire future services. 

GRIEVANCE PROCEDURE. I am aware that if, for some reason, I am dissatisfied with the services I am receiving, I may speak to my therapist about it. If, at any time, I believe that my therapist has not responded appropriately, I may contact the coordinator of the center. I understand that the administrative personnel will address my concerns and notify me of the resolution in a timely manner.

REFERRALS. If, for any reason, the center is not able to meet my needs, I am aware that the appropriate referrals will be made. I am aware that the center is commited to providing high quality services to all of their clients. I have had an opportunity to read this Consent Form, to ask any questions I may have, and I agree with all of the provisions contained above. I understand that if I have any reservations, I should not sign this statement.

CONSENT TO ONLINE PLATFORM REGISTRATION. By signing up for services with Sanctuary by Solace, I understand that I will be registered on Sentinel, our secure online platform used for managing appointments, records, and communication. I am aware that my information will remain confidential and protected, and I consent to this registration as part of my care.

CONSENT

I have read the information provided above. I understand the information contained in this form and agree with the terms stated within.