Adult Somatic Attachment Psychotherapy
Consent Form

PLEASE DO NOT FILL OUT THIS FORM BEFORE CONFIRMING AN APPOINTMENT WITH ME.

DEAR CLIENT,
I am a Registered Social Worker (08439) with the BCCSW and as such, I am governed by the College’s Bylaws and Code of Conduct. I am a Registered Clinical Counsellor (15802) with the BCACC. In order to be well informed about my policies and your rights as a client, I am providing you with this material. Please read this carefully and, if you need clarification on any of this information, please ask me before signing this form.

THE PROCESS OF CHANGE
Therapy involves a great commitment of time, money and energy, so a therapist should be carefully chosen. It is important to feel comfortable and optimistic with the person you choose. Change is sometimes easy and swift, but more often slow and frustrating. As with any powerful treatment, there are both benefits and risks associated with therapy. Risks might include experiencing uncomfortable levels of feelings like sadness, guilt, anxiety, anger and helplessness, or loneliness; recalling unpleasant aspects of your history; making poor decisions; delaying actions; and difficulties with other people. A host of positive changes are possible, such as: lifting depression and decreasing anxiety; reduction of elimination or trauma symptoms, freedom to experience your full range of emotions; greater integration and increased alignment with who you are; increased creativity; and feeling more connected to self, others and the sentient world.

CONFIDENTIALITY
You have the right to privacy, confidentiality and professional behavior. You also have the right to see files or information I keep regarding your work with me. Confidentiality is a serious concern for me. I will not divulge any information shared in our work together without your express, written permission, except under the following circumstances:
That, in my opinion, you are a danger to yourself or others

That, from the information you share with me, I conclude that you or someone about whom you have been speaking is in danger.
That a court of law orders me to release any notes which I have kept concerning our sessions.

CONSULTATION
I will, during the course of our work together, be seeking professional consultation. This is to ensure that you receive to best possible care that I can offer. While in consultation I will need, at times, to describe some practical details of our sessions. The same boundaries will apply to these details as I have described will apply to my notes.

SESSION FEE & LENGTH
Fees are $120.00 for 60 minutes. Payment is due after each session, which may be made by cash or cheque to Sather Child Counseling & Consulting Inc. or e-transfer to Dawn@SatherChildCounseling.com. Receipts’ will be provided when payment has been received. A $50.00 administration fee will be charged for NSF cheques.

CHANGE OF CANCELLATION OF APPOINTMENT
I require 24-hour notice to change or cancel your appointment; session fees will be charged for missed appointments and late cancellations.

SICKNESS, COLDS, and FLUS
Please call and reschedule if you are ill or experiencing any cold or flu symptoms. I will do the same. See COVID19 Practice Guidelines.

VIDEO/VIRTUAL COUNSELING AND PRIVACY POLICY
My counseling practice is governed by the BCCSW Standards of Practice; the Technology Standards of Practice and the BC Provincial laws and regulations regarding Confidentiality and Information Sharing (PIPA). For video/counseling sessions, I use a secure video service provided by “On Call”. “On Call” privacy policy can be located at https://oncallhealth.ca/privacy/

CONTACT OUTSIDE OF SESSIONS
I generally receive and reply to voice or email messages Monday through Friday at the end of the day. Telephone calls that are primarily therapeutic in nature and extend more than ten minutes will be pro-rated and billed at the usual rate.

EMERGENCY/CRISIS
The nature of my practice is that I am unable to offer crisis response or ongoing support outside of sessions. If you are in crisis and need to speak with someone, please call the Vancouver Island Crisis Line at 1-888-494-3888.

ACKNOWLEDGEMENT AND INFORMED CONSENT
By signing below, you are indicating that you have been made aware of the benefits and risks of Sather Child Counseling & Consulting Services, as well as, the limits to confidentiality. You acknowledge that you have had the opportunity to carefully read this document and to ask, and have answered, any questions or concerns you have. You acknowledge that you have understood the information contained in this document. You may have a copy of the signed consent, if requested.

Thank you for the opportunity to provide clinical counseling services.

Kindly,

Dawn Sather, MSW, RSW, RCC

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