Informed Consent for Individual Clinical Psychotherapy

You have been referred to PAUL BROWN COACHING for individual psychotherapy, which will be delivered in person, via telephone, or via video conferencing. This consent form outlines what psychotherapy will involve as well as the benefits/risks of participating in psychotherapy and the limits of confidentiality.

Psychotherapy is beneficial to most individuals coping with a wide variety of life’s challenges. With that being said, it is a highly individualized process and there is no guarantee of success. Treatment can assist in helping one become better at understanding and challenging unhelpful thoughts, feelings, and behaviors.

Clinicians at PAUL BROWN COACHING use a variety of evidence-based treatments to help you to feel better. Keeping scheduled appointments and following through on recommendations is the best way to benefit from treatment. Your clinician understands that at times, it may be difficult to talk about some topics which can bring up strong emotions and memories. This may result in a different level of awareness of self, others, and the world. You are encouraged to speak with your clinician about the process of treatment and how PAUL BROWN COACHING can effectively meet your needs.

Psychotherapy may involve the following: (a) multiple 50-minute sessions, (b) gathering information about your psychosocial history, (c) review of collateral documentation, (d) contact with collateral sources if consent is provided (e.g. parent, spouse/ partner, health care provider), (e) psychometrics to inform treatment outcomes, (f) writing session notes of your progress, (g) and, if required, a written treatment summary.

The psychotherapy you are participating in with PAUL BROWN COACHING is intended to address your treatment goal(s). Your participation is voluntary, and you can withdraw your participation at any time. Your involvement and progress in psychotherapy will not be disclosed without your written consent. Your consent must be in writing, and we will not release information about your treatment based solely on a telephone request. However, there are certain limitations to confidentiality.

 

LIMITATIONS OF CONFIDENTIALITY INCLUDE:

a) if a judge orders PAUL BROWN COACHING to make your report available;

b) if it is determined that you are at imminent risk of serious harm or ending your life;

c) if you disclose that you are intending to harm another person, I would attempt to inform that person as well as contact the local police;

d) if you disclose abuse or neglect of a child under 16, the Children’s Aid Society (CAS) must be notified;

e) if you disclose historical sexual abuse, which has not yet been reported, and the abuser remains in a position of trust over children, CAS will be notified;

f) if you disclose that you are the victim of sexual abuse perpetrated by a member of a regulated health profession, that individual’s regulatory body must be informed;

g) if you disclose that an individual residing in a Long-Term Care facility or retirement home is being abused or neglected, the director of the Ministry of Health and Long-Term care and/or Retirement Homes Regulatory Authority must be notified.

Privacy Statement:

PAUL BROWN COACHING takes protecting your privacy very seriously. The collection, use, and disclosure of your personal health information is in accordance with the laws of Ontario, as well as professional regulations and ethical standards. Full details regarding applicable laws and standards can be found at the websites of the College of Registered Psychotherapists of Ontario and the Ontario Ministry of Health and Long Term Care.

 

Collection and Retention of your Personal Health Information:

We collect information about you that relates to your identifiable characteristics (e.g., gender, birthday, address, phone number), as well as background information and health history that assists us in providing you with mental health services. With your consent, we may also collect information about you from others to assist with your care. This can include, but is not limited to, your spouse, physician, case manager, or other clinicians.

Personal health information is protected by privacy legislation (e.g. the Personal Health Information Protection Act, PHIPA). We collect information about you on consent forms, in session notes, in billing information, contact records, or any correspondence from others we have received relating to your service. This information is held on an electronic medical record that adheres to the privacy standards of the profession and is stored on encrypted servers held in Canada.

Telehealth video sessions are end-to-end encrypted, meeting the professional standard for healthcare privacy. When a video session is complete, the video feed ends; it is not stored on any server.

Any physical copies of documentation are scanned and saved onto this medical record, then micro-shredded. Electronic information stored on a computer is encrypted and password protected.

According to standards of practice set forth by the college, your medical record is kept for 10 years respectively, from your last date of clinical contact. Electronic information is then deleted.

If you contact PAUL BROWN COACHING through our website, we only retain the information from this email for the purpose of coordinating your intake phone appointment.

 

Right to Access Your Personal Health Information:

With only a few exceptions, you have the right to access and request a copy of your medical record. I reserve the right to charge a nominal fee for record copying. If you believe there is information in your medical record that is not accurate, you can make a written request to correct your record. This applies to factual information, not clinical opinion. If there is agreement regarding the error, we will make the necessary changes. Should we disagree with the changes you request, it is your right to file a notice of disagreement as part of your formal record.

Exceptions involving access to your record include information that contains personal health information about another individual; that person’s information must be removed from the record before you have access. Other exceptions include accessing information that could result in serious harm to someone’s treatment or recovery (including your own), as well as serious bodily harm to yourself or others. We will discuss any of these unique concerns with you should they ever arise.

 

Disclosure of your Personal Health Information:

With a few exceptions, your personal health information will not be disclosed to anyone without your knowledge and consent. Your consent must be in writing and we will not release information about you based solely on a telephone request. When consenting to the disclosure of your personal health information, you may direct us to share all or only part of your information.

Limits to confidentiality include:

a) if records are summoned by a court of law;

b) if it is determined that you are at imminent risk of serious harm or ending your life;

c) if you disclose that you are intending to harm another person, we would attempt to inform that person as well as contact the local police;

d) disclosure of abuse or neglect of a child under 16, the Children’s Aid Society (CAS) must be notified;

e) historical sexual abuse, which has not yet been reported, and the abuser remains in a position of trust over children, CAS will be notified;

f) if you disclose being the victim of sexual abuse perpetrated by a member of a regulated health profession, that individual’s regulatory body must be informed, and;

g) abuse or neglect of an individual residing in a Long-Term Care facility or retirement home.

In situations where confidentiality must be breached, the disclosure of your information includes only what is reasonably necessary for the purpose of that disclosure. If your mental health services are being paid for by a third party (e.g. extended health care benefits, Veterans Affairs), these payers at times ask for your consent so that we can disclose information to assist with adjudication for entitlement to this funding. We will discuss with you a third party’s request for your information and we encourage you to ask any questions you may have at any time.

Any emails to allied providers (e.g. case manager) that assist with the coordination of your service (with your consent) are marked confidential and you are only referred to by initials in the email.

Our licensing body may conduct external audits of files, which involves accessing client records to ensure that your clinician is adhering properly to the strict documentation standards of the profession. Should we be audited, you will be notified, and we will remove any identifiable client information to protect your privacy.

If your therapist dies or becomes incapacitated, a designated clinician will retain your records for safekeeping. This individual does not review your records but acts as guardian of your records and you would be contacted as to where your records are held.

If you have any further questions, please talk to Paul Brown. Should any concerns not be resolved to your satisfaction, you may contact the Ontario Privacy Commissioner.

Payment of Services:

Payment for services is required at the time of each appointment. If you have insurance coverage, you are required to pay upfront and will be provided a receipt which you can submit for reimbursement. You can also save your receipts to claim as a healthcare expense with your income tax. Payment for all services is through E-Transfer.

Receipts for service will be e-mailed to you. If you have sent an e-transfer payment prior to receiving your service, and you do not end up receiving your service as scheduled, these funds will be kept in trust and applied as a credit on your account towards a rescheduled service.

Rates for sessions may vary depending on the service being provided. We will discuss rates prior to your first session.

 

Additional Services

● Letter and Form Completion (each 15-minute interval) $50.00;

● Photocopying of your file (first 20 pages) $25.00;

● Photocopying of your file (each additional page after the first 20) $0.25 per page;

● Telephone Consultation (first 15-minutes) – Free;

● Telephone Consultation (each additional 15-minutes) $50.00.

Any additional service not outlined above will be billed at $50.00 for each 15-minute interval unless otherwise notified. If possible, this will be discussed with your clinician prior to services rendered.

Accounts overdue will be charged at an interest rate of 1.5% per month. This will be imposed on accounts that remain unpaid one month after your invoice is issued. If you have any questions regarding the practice’s billing policies, please discuss the matter directly with me.

Cancellation Policy:

The appointment time you have booked is reserved exclusively for you. If you are unable to keep an appointment, please advise us as soon as possible. Cancellation or rescheduling of an appointment requires twenty-four (24) hours advance notice to avoid the potential of being charged late penalties. Where possible, due to cancellations related to weather, your clinician will discuss with you the possibility of a phone or video session instead of in-person.

Late Appointments: If you arrive late, your session cannot be extended into the next client’s time. This policy is designed to respect the time management and scheduling for all other clients.

Consent and Waiver for the use of Artifical Intelligence in Note Taking:

As part of providing psychotherapy services, Paul Brown Coaching may use an artificial intelligence (AI) tool to assist with note-taking and documentation. The AI platform used is compliant with PHIPA (Personal Health Information Protection Act), PIPEDA (Personal Information Protection and Electronic Documents Act), and HIPAA (Health Insurance Portability and Accountability Act) standards for privacy and security.

The AI tool functions only as an administrative support for creating and organizing notes. All information processed is protected with encryption and stored in compliance with applicable privacy legislation. At no time will the AI tool make clinical decisions, provide treatment, or replace my professional judgment. You retain the right to request that AI not be used in the documentation of your sessions. While all reasonable safeguards are taken, you acknowledge and accept that no system can guarantee absolute protection of personal health information.

Office Hours:

Office hours are by appointment only. Clinicians are available for contact outside of office hours via phone and email. Clinicians will always strive to return your phone call/email within forty-eight (48) hours, except for weekends and holidays. Please be aware that clinical issues will not be addressed over e-mail due to confidentiality issues.

Emergencies:

Please do not contact the office in emergencies. You are encouraged to contact 911 or visit your nearest emergency room.

 

Complaints:

If you have concerns about your service, we hope that you will first discuss this with us. Complaints are taken seriously and will be handled respectfully. If you believe your therapist has not responded to your concern or is acting unethically, you may report your concern to their licensing body (e.g. College of Registered Psychotherapists of Ontario), who have an obligation to investigate ethical violations to protect the public.

 

Social Media:

Please do not use texting, posting, or messaging on any social networking sites to contact your clinician. These sites are not secure, and your clinician is unlikely to see this form of communication in a timely fashion. There is a therapeutic relationship between a client and clinician in which engaging on social media can compromise your confidentiality. It may also create the possibility that these exchanges become a part of your medical record and would need to be documented in your chart. If you need to contact your provider between sessions, the best way to do so is by phone and/or email.

 

Email:

Clinicians at PAUL BROWN COACHING may use email to interact with you regarding administrative aspects of your treatment/assessment only. We will not discuss in email any content related to your therapy sessions or assessment, as email is not entirely secure or confidential. If you choose to communicate with your clinician by email, be aware that all emails will be retained in the logs of your internet service providers. Theoretically, these logs can be read by the system administrator of the internet service provider. Any emails received by your clinician from you and responses sent will become a formal part of your medical chart.

 

Use of Search Engines:

It is NOT a regular part of your clinicians’ practice to search for clients on any search engines (e.g. Google, Facebook, etc.).

 

Business Review Sites:

You may find PAUL BROWN COACHING on sites such as Yelp, Rate My MD, Yellow Pages or other places which list businesses. Some of these sites include forums in which users rate their clinicians and add reviews. Many of these sites mine search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you find the practice’s listing on any of these sites, please know that the listing is NOT a request for a testimonial rating or endorsement. You always have the right to express yourself on any site you wish. But due to confidentiality, your clinician cannot respond to any review whether it is positive or negative.

Clinicians at PAUL BROWN COACHING hope that you will bring any concerns you have with your treatment to the attention of your clinician, even if you decide not to work with us, so that we can work through your concerns and help you achieve the best possible outcome.

 

AUDIO AND VISUAL RECORDING OF SESSIONS:

PAUL BROWN COACHING recognizes the practice and therapeutic benefits of personal electronic devices (PED’s), such as listening to music or watching videos, maintaining contact with friends and family, accessing the Jane Patient Portal, and education purposes. Many PEDs have the ability to take photographs, record videos, access websites and material on the internet, and be used to communicate by email, instant messaging systems, and through social media.

Please note, however, that using PEDs to photograph or record others during therapy without explicit and informed consent compromises the privacy and confidentiality of Clients, Natural/Familial supports, and the Therapist. For this reason, any audio and visual recordings of sessions are expressly prohibited without prior consent from both the treating therapist and the Client. Clients, Family/Natural Supports, and the Therapists may not take any photos, videos recordings, or audio recordings within PAUL BROWN COACHING office spaces, or of the virtual therapy session, without the explicit and informed consent of involved person(s), to protect privacy and safety of all involved.

Violation of this policy will result in the PAUL BROWN COACHING requesting the individual delete the content from their device as well as any online platform to which it may have been uploaded. The therapist and PAUL BROWN COACHING reserve the right to terminate services should a Client violate this policy.