• Telehealth Registration Form

  • Thank you for choosing me as your psychotherapist! We value our clients. A therapeutic relationship works because each party holds certain rights and responsibilities. The intent of this form is to inform you of our policies and clarify the nature of a therapeutic relationship.

  • What to expect

  • This sets out how we will work together, what you can expect from me, and what I need from you. Please read it and ask about anything that is unclear before you sign.

     

    About me and my training

    I hold a Master's in Clinical Mental Health Counseling from UNC-Pembroke and have received a LCMHCA licensure in the US, awarded 2024. I have been in practice since 2024. I am working toward accreditation with the Irish Association for Counselling and Psychotherapy and work to its Code of Ethics and Practice. Counselling and psychotherapy are not yet statutorily regulated in Ireland, which means there is no state register. My accountability runs through IACP and through regular clinical supervision.

     

    Confidentiality

    What you tell me is confidential. I will not disclose that you are a client here, or anything you say, without your written consent. There are four circumstances where I may have to break that, and I will tell you if any of them arise unless doing so would increase risk:

    • Where there is a serious and immediate risk to your life or safety, or to someone else's.
    • Where I have a concern about the welfare or protection of a child, which is reported to Tusla.
    • Where I hold information about a serious offence against a child or vulnerable adult, which the Criminal Justice (Withholding of Information) Act 2012 requires me to report to An Garda Síochána.
    • Where a court orders disclosure.

    Wherever possible I will discuss this with you first and involve you in what happens next.

     

    Supervision

    All therapists in Ireland are required to work under regular clinical supervision. I discuss my client work with my supervisor, who is also bound by confidentiality. Your name and identifying details are not used.

     

    Sessions and fees

    Sessions last 50 minutes and cost €70. Reduced-fee places are available on request and are limited in number, depending on need. Payment is due on the day of each session by Revolut. Receipts are issued for every session. Some health insurers refund part of the cost of counselling and you claim that directly from them.

    If you need a letter or report, this is charged at €10 and takes up to one week. I do not provide documentation for assistance animals, disability or welfare claims, immigration or international protection applications, custody or access proceedings, or fitness-for-work assessments. If I am required to attend court or produce a report for legal proceedings, my time is charged at €100 per hour, agreed in writing in advance.

     

    Cancellations

    See the separate Appointment and Cancellation Policy, which forms part of this agreement.

     

    Contact between sessions

    This is not a crisis service. I do not provide on-call, out-of-hours, or emergency cover. I check my on working days and aim to respond within two working days. Between-session contact is for scheduling, not for therapy.

    If you are in crisis: call 999 or 112, contact your GP or the out-of-hours GP service, or go to your nearest emergency department. Samaritans are on 116 123, free, any hour. You can text HELLO to 50808. Pieta is on 1800 247 247 or text HELP to 51444.

     

    Records

    I keep brief notes of each session. These are held securely and kept for seven years after our final session. How your information is handled is set out in full in the Privacy Notice.

     

    Meeting outside sessions

    If we meet by chance in public I will not approach you or acknowledge you first, to protect your privacy. If you say hello, I will of course respond, and will keep the exchange brief.

     

    Ending

    You can end therapy at any time and do not need to give a reason. I would encourage a final session to close the work properly, but that is your choice. I may also end the work, for example if I judge that another therapist or service would serve you better, if sessions are repeatedly missed, or if fees go unpaid. In any of those cases I will discuss it with you and offer referral options.

    If six weeks pass without contact, I will assume the work has ended and close your file. You are welcome to make contact again at any point.

     

    If you are unhappy

    Please tell me directly first. Most concerns can be resolved in the room. If that does not work, or you would rather not raise it with me, you can complain to the IACP Complaints Committee at +353 1230 3536. Nothing in this agreement limits your right to make a complaint, and doing so will not affect your care.

  • Client Info/Demographic Form

  • Format: (000) 000-0000.
  • Date of birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Demographic
  • Date*
     - -
    2 digit day, 2 digit month, 4 digit year
    • Online Therapy Consent 

    • Sessions are held by video using Google Meet. This form covers what that means in practice.

       

      What you need

      A private space where you will not be overheard or interrupted, a device with a working camera and microphone, and a stable internet connection. Headphones are recommended. Please treat the session as you would an in-person appointment: not in transit, not driving, not somewhere public.

       

      What is different about working online

      Online therapy is effective for many people and suits some presentations better than others. It also has limits. I see less of you than I would in a room, non-verbal cues are harder to read, and a poor connection can interrupt the work at difficult moments. If either of us judges that online sessions are not working well for you, we will discuss moving to possibly in-person or a referral.

       

      Technology and its risks

      No online platform is completely secure. There is a small risk of technical failure, dropped connections, or unauthorised access. I use Google Meet, which provides end-to-end encryption / encryption in transit, and I take reasonable steps to protect the session. I cannot guarantee against every risk.

      If the connection fails and cannot be restored within 10 minutes, I will call you on {phoneNumber} and we will either continue by phone or reschedule. 

       

      Your appointment link

      Do not share your session link with anyone. If someone else is joining a session, that is arranged with me in advance.

       

      Recording

      Sessions are never recorded by me. Please do not record any part of a session without agreeing it with me first. Recording a session without the other person's knowledge damages the working relationship and may end it.

       

      Where you are

      I need to know what country you are in for each session, because if an emergency arises I need to be able to direct help to the right place. Tell me in advance if you will be outside Ireland for a session. I may not be able to work with you while you are in another jurisdiction, depending on that country's rules.

       

      In an emergency

      Online sessions are not suitable for crisis support and I cannot reach you physically. If you are in danger, call 999 or 112, contact your GP or the out-of-hours GP service, or go to your nearest emergency department. Samaritans: 116 123. Text HELLO to 50808. Pieta: 1800 247 247, or text HELP to 51444.

       

    • Consent to Share Information 

    • Nothing about your therapy is shared with anyone outside this practice unless you ask for it. If you do want something shared, whether with your GP, a psychiatrist, a solicitor, an insurer, or a family member, it happens through a separate written consent that you complete at the time. This section explains how that works so you know what to expect if the situation arises.

       

      You decide the specifics.

       

      A consent covers one named person or organisation, one defined set of information, and one stated purpose. It is not a general permission. Options usually include confirmation that you attend and the dates of attendance, a summary letter of the work to date, assessment or intake information, or correspondence with a named healthcare professional. You choose which of those apply.

       

      Process notes are treated differently.

       

      Your therapist keeps brief personal notes that are held separately from your main file. These are not released under an ordinary consent. If you want them included, it has to be requested and agreed separately, and there are limits on what can be shared where notes refer to other people.

       

      It has an end date.

       

      A consent lasts until the date you specify, or twelve months from signing if you do not set one, or until you withdraw it.

       

      You can withdraw at any time.

       

      In writing or verbally, without giving a reason, and it takes effect immediately. Withdrawing cannot undo anything already sent.

       

      Once information leaves, it is out of our hands.

       

      The person or organisation receiving it has their own obligations under GDPR and their own retention rules, which may differ from ours.

       

      Signing is never a condition of treatment.

       

      You do not have to consent to any disclosure in order to be seen, and declining has no effect on your care. Equally, consenting does not oblige your therapist to share something they judge would be harmful to you, or that would reveal information about another person without their consent.

      You are given a copy of any consent you sign.

    • Appointment and Cancellation Policy 

    • Your session time is reserved for you and is not offered to anyone else. This explains what happens when a session cannot go ahead.

       

      Notice period.

      Please give at least 48 hours' notice to cancel or reschedule, by email to augustemoryraines@gmail.com.

       

      Late cancellation and non-attendance.

      A session cancelled with less than 48 hours' notice is charged in full. If you do not attend, or arrive more than 30 minutes late, the session is charged in full. If you arrive late, we finish at the scheduled time, as another appointment may follow.

      Illness and emergencies. Sudden illness, bereavement, and genuine emergencies are not charged. Tell me as soon as you reasonably can. I do not ask for a doctor's note.

       

      If I cancel.

      If I have to cancel, you are not charged and I will offer you an alternative time as soon as possible. If I cancel with less than 24 hours' notice for any reason other than an emergency, your next session is half fee.

       

      Repeated missed sessions.

      If two sessions are missed without notice, I will ask to talk about whether the timing or arrangement is working. Attendance is often connected to the material being worked on rather than being a practical problem, so it is worth discussing rather than assuming the work should end. If it continues, I may end the work and offer a referral.

       

      Unpaid fees.

      If fees fall more than 2 weeks behind, I will raise it with you and we will agree how to deal with it. If it is not resolved, I may pause or end the work. I will always offer referral options rather than leaving you without support.

       

      Breaks and holidays.

      I will give you at least four weeks' notice of planned breaks. Please give me as much notice as you can of yours.

    • Privacy Notice 

    • This explains what personal information I hold about you, why, and what rights you have over it. It is issued under Articles 13 and 14 of the GDPR.

       

      Who is responsible


      I am the data controller for your information. You can contact me at augustemoryraines@gmail.com. I have not appointed a Data Protection Officer, as a practice of this size is not required to.

       

      What I collect


      Contact details (name, address, phone, email), your date of birth, your GP's details, an emergency contact if you provide one, what you tell me about your health and circumstances, brief session notes, appointment and payment records, and any correspondence about your care.

       

      Why I hold it, and on what legal basis


      I process your contact and appointment information to provide and administer the service you have asked for, which is a contract between us under Article 6(1)(b).

      Information about your health and personal circumstances is special category data. I process it under Article 9(2)(h), which covers the provision of health care by a professional bound by an obligation of professional secrecy, together with the Data Protection Act 2018.

      Where I share information with someone outside the practice at your request, that is done on your explicit consent under Article 9(2)(a), recorded separately.

      I keep financial records because tax law requires it, which is a legal obligation under Article 6(1)(c).

       

      Who sees it


      Nobody, in the ordinary course of the work. There is no administrative staff and no third party with routine access to your file.

      The limited exceptions are my clinical supervisor, who discusses my work with me without your name or identifying details; Google, which hosts video sessions; and Tusla, An Garda Síochána, emergency services, or a court, in the circumstances set out in the Therapy Agreement.

      I do not sell your information, use it for marketing, or make any automated decisions about you.

       

      Information held outside the EEA


      Google Meet is based in the US. Your information is transferred there under the EU-US Data Privacy Framework / Standard Contractual Clauses, and I have a data processing agreement in place. If you would prefer not to use this platform, tell me and we can discuss alternatives.

       

      How long I keep it


      Clinical records: seven years from your final session. Financial records: six years, as required by Revenue. After that, records are securely destroyed.

       

      Your rights


      You can ask for a copy of your records, which I will provide free of charge within one month. You can ask me to correct anything inaccurate. You can ask for erasure or restriction, though I may not be able to comply in full where I have a legal or professional obligation to retain records. You can object to processing, ask for your data in a portable format, and withdraw any consent you have given, which takes effect from that point onward.

      Session notes may refer to other people. Where that happens I may need to redact those parts before releasing a copy.

      To make any of these requests, contact me at augustemoryraines@gmail.com.

       

      Complaints


      If you are unhappy with how I handle your information, please tell me first. You also have the right to complain to the Data Protection Commission, 21 Fitzwilliam Square South, Dublin 2, D02 RD28, or at dataprotection.ie.

       

      Security


      Records are held encrypted, on a password-protected device. Paper notes, where kept, are stored separately from your contact details.

       

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