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

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

First Emergency Contact Details

This person should be someone that is your next of kin. 

Second Emergency Contact Details

This person should be someone that is reachable for us to contact. 

If you live alone or do not reside with your next of kin, please provide the contact details of someone who lives nearby or is easily accessible to your household.

THE ONLINE PSYCHOTHERAPY PROCESS. Online psychotherapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.

• I am aware that online psychotherapy 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 online psychotherapy 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.

CONFIDENTIALITY. 

• 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.

LIMITATIONS OF ONLINE PSYCHOTHERAPY. 

• I understand that online psychotherapy carries certain risks and potential consequences, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
• I understand that technology issues may occur and disrupt online psychotherapy sessions. If this happens, I will end the call and attempt to reconnect as soon as possible. Should the issue persist, I will coordinate with my therapist or the clinic coordinator to determine the best way to resume the session.
• I understand that the therapist is not responsible for any lapses or breaches of confidentiality, equipment failures (e.g., laptop, camera, internet connection) due to my actions or errors, or disruptions caused by third-party interference.

IN EVENTS OF CRISES. 

• I understand that if I am experiencing suicidal or homicidal thoughts, severe psychotic symptoms or mental health crises that cannot be resolved remotely, it may be determined that online psychotherapy services are not appropriate and a higher level of care is required.
• I understand that I am responsible for informing the therapist if I am at risk of harming myself or others. I acknowledge that the therapist may refer me to more appropriate services if they determine that such a referral is in the best interest of my well-being and safety.
• I understand that in events of crises, my therapist may reach out to my emergency contact person and action may be taken in life-threatening situations. At least one of those contacts are someone who lives nearby/ accessible to my household, and the other contact is my next of kin. 

LENGTH AND DURATION ON ONLINE PSYCHOTHERAPY 

• I understand that therapy length varies with the nature of my issue, thus making predictions of the treatment length is challenging.

• I understand that online psychotherapy will last for 50 minutes, leaving 10 minutes for buffer time. 

• 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 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.

CONSENT

I have read the information provided above. I understand the information contained in this form and agree with the terms stated within. I agree to participate in online psychotherapy with Solace Wellness as part of my treatment plan.