60 Menzies Street, Victoria BC V8V 2G2 tel 250.383.2451 www.monicakingsbury.com firstname.lastname@example.org
Monica Kingsbury is a Registered Clinical Counsellor and member of the BC Association of Clinical Counsellors (registration #0678).
AGREEMENT FOR PROFESSIONAL SERVICES
I understand that counselling sessions are confidential and that information will not be disclosed without my signed consent. Some exclusions to confidentiality do exist such as child welfare concerns, demonstrating hurtful intentions to self or others, subpoena/court order or medical emergency.
I understand that a professional therapeutic relationship is voluntary and that I may terminate therapy at any time and that a closure session is generally recommended.
I understand that payment is due at the time of the session. In the event of a missed appointment or late cancellation (fewer than 24 hours) payment is due.
Agreement for Telehealth Services
Confidentiality - The laws that protect the confidentiality of your medical information in the office also apply to telehealth sessions, including mandatory and permissive exceptions to confidentiality. You and I both agree to keep the same privacy safeguards as during our in-person sessions. The environment should be free from unexpected or unauthorized intrusions or disruptions to our communication. There is a risk of being overheard by a third party near you if you do not conduct the session in an enclosed private room, with reasonable sound barriers, and with no one else present or observing. You and I both agree to not record the telehealth sessions without prior written consent of both parties.
Consent - You have the right to opt in or opt out of the methods of telehealth communication at any time, without affecting your right to future care or treatment.
Security - Due to the complexities of electronic media and the internet, risks of telehealth include the potential for release of private information, including audio and images. So, we cannot fully guarantee the security of telehealth sessions. You are responsible for information security on your computer, laptop, tablet, or smartphone.
We use software with encryption to maximize your confidentiality.
Payment- Just like in-person services, telehealth services are a professional service, and a fee is charged at the same rate as in-person services. Even when health insurance covers in-person services, health insurance may limit or deny coverage of telehealth services. Please confirm and know in advance what your insurance may or may not cover.
I have read and agree to the terms of the above Client Agreement for Professional Services.