Couples Therapy Contract

Couples therapy AGREEMENT

This agreement is between Daniela Gallini ( therapist) and the couple named below :
Partner 1*

First NameLast Name
E-mail *
example@example.com
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
Partner 2*

First NameLast Name
E-mail *
Phone Number*

Area CodePhone Number
Address (only complete is its different from partner 1)

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
  
  Couples therapy is a collaborative process and the duration depends on the nature of your relationship concerns. Some couples prefer to work with an open contract, others with a fixed number of sessions followed by a review. In all cases, we will review our work every 6 sessions. This allows us to assess whether your needs as a couple are being met and to make adjustments or set new goals if needed.
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 both partners understand and agree to the 48 hours cancellation policy ?

YesNo
- Confidentiality
  
  In couples therapy, the relationship is considered the client. This means information shared in joint sessions is part of the shared therapeutic work.
  
  Occasionally, individual sessions may be offered. If so, it will be important to clarify what is or isn't brought back into the joint work. As the therapist, I do not keep secrets between partners. If one partner shares something individually that is relevant to the relationship, I will encourage them to bring it into the couple sessions. If not, I may need to bring it in myself.
  
  As part of my professional standards, I regularly discuss my work with a qualified clinical supervisor under strict confidentiality. Your identities will be kept anonymous in that context.
  
  Exceptions
  
  In rare circumstances, I may need to break confidentiality:
  
  If I believe there is a serious risk of harm to yourself or others.
  If I cannot contact you but believe you are in danger.
  If there is a legal requirement to disclose information (e.g. a court order).
  Where possible, I will always discuss this with you first.
- 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
  
  Communication Between Sessions
  
  To maintain therapeutic boundaries, please contact me via email at danielatherapy1@outlook.com and only for practical matters such as cancelling or rescheduling appointments. Please avoid discussing session content by email.
  
  Influence of Alcohol or Substances
  
  Sessions will not take place if either partner is under the influence of alcohol or any substances that impair judgment or emotional availability.
  
  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.
Partner 1: I agree and understand to all of the above, Signature*

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Partner 1 : I agree and understand to all of the above, Signature*

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Couples therapy AGREEMENT