Informed Consent for Psychotherapy Services Logo
  • Informed Consent for Psychotherapy Services

  • Psychotherapy offers individualized support on psychological, emotional and social issues.  It is beneficial towards strengthening internal resources to deal with external challenges of daily life and irregular hardship.  As a byproduct of these benefits, psychotherapy also carries the risk of psychological discomfort, emotional distress, and interpersonal/social/professional ‘growing pains’.

    To maximize therapeutic benefit and minimize risk, the following outlines what you should expect from your psychotherapist and what you, in turn, should expect to offer.

    Your psychotherapist (Khadijah Kanji, MSW, RSW) should:

    • Work with you at the onset of the relationship to develop goals, to be revisited and revised as necessary
    • Centre your needs and well-being in all conversations and actions
    • Create an environment that invites you to disagree, correct or redirect 
    • Speak to you with respect, kindness, and with the aim of understanding your thoughts, feelings and priorities
    • Apply therapeutic knowledge and skills so as to best direct you in the pursuit of your goals
    • Refer you to additional or alternative resources as deemed necessary for progress on your goals or other issues that arise
    • Be clear, reliable and prompt in communication about logistics (e.g. scheduling or rescheduling sessions, fees)
    • Adhere to the ethics and standards of the relevant professional regulatory college, i.e. The Ontario Association of Social Workers and Social Service Workers 

    You (the client) should:

    • Arrive on time to sessions
    • Work with your psychotherapist to schedule sessions at intervals sufficiently regular to enable progress on your goals
    • Engage in your sessions with willingness and openness
    • Complete, as applicable and to the best of your ability, the ‘homework’ that is agreed upon in sessions
    • Be open about any concerns or disagreements you have with your psychotherapist about the content and direction of the sessions
    • Be clear, reliable and prompt in communication about logistics (e.g. scheduling or rescheduling sessions, fees)

    Nature of Psychotherapy
    Psychotherapy is a voluntary pursuit.  Even when it carries the possibility for psychological or social discomfort, it should always facilitate the maximization of your well-being.  You have the right to refuse any recommended service or terminate the relationship at any time.

    Privacy, Confidentiality & Record-Keeping
    Psychotherapy is confidential, which means that your psychotherapist is not permitted to disclose the fact of your therapeutic relationship or the content of your sessions without your express consent, except for in the following limited circumstances:

    • Your psychotherapist is aware of abuse or neglect of a child or a dependent adult
    • Your psychotherapist believes there is a risk of imminent harm to you or someone else
    • You disclose abuse by a regulated health care provider
    • By court order

    In all situations, your psychotherapist will attempt to notify you in advance and will limit disclosure to only what is pertinent and to the appropriate authorities.

    Psychotherapy is also private, which means that the software/practices used to facilitate your virtual appointments and to store your clinical records is compliant with relevant privacy law.  

    To facilitate effective treatment and in keeping with the standards of your psychotherapist’s regulatory body, your psychotherapist will maintain a written summary of your sessions and communications.  You have the right to access your clinical record and request changes to the record if you believe there are inaccuracies.  Any requests for disclosure made on your behalf (for example, from your lawyer) will require your authorization, unless required or permitted by law (as outlined above).

    If you have any questions or concerns about confidentiality, privacy or record-keeping with respect to your particular file, please email admin@mentalrefuge.ca

    Fees
    For uninsured clients, your sessional rate is agreed upon with your psychotherapist and is based, in part, on your particular needs and financial circumstances.  The rate is subject to possible increases, with 30 days notice.  Your fee is due on the day of your session and is payable by Interac e-transfer.  If you would like to request an alternative payment schedule, you must inform your psychotherapist 48 hours before your session and efforts will be made to accommodate.  If a payment is missed, you will not be able to complete any following sessions until payment has been remitted or you have arrived at an agreement with your psychotherapist.   

    Cancelled and Missed Sessions
    If you are unable to attend a session, you are required to provide 24 hours notice to your psychotherapist.  Failing to do so will result in a charge for the missed appointment that is equivalent to your normal sessional rate. 

    Communications  
    Communication outside of scheduled sessions is for administrative purposes only (i.e. scheduling or rescheduling sessions).  If you are in crisis, call or text 9-8-8 for immediate support (toll-free, open 24/7)

    Statement of Informed Consent
    I have had sufficient time to consider the above information and have asked any necessary questions.

    I hereby consent to receive psychotherapy from practitioner Khadijah Kanji (MSW, RSW) at Mental Refuge Therapy Services.

  • Powered by Jotform SignClear
  •  - -
  • Should be Empty: