Child-Parent Psychotherapy Consent Form

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

DEAR PARENT(S),
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.

THERAPY
Therapy involves a great commitment of time, money and energy, so a therapist should be carefully chosen. As a Therapist, my role is to:
• Provide the child/parent with an opportunity to voice their own feelings and concerns;
• Provide parent(s) with support to help them build security in the child-parent relationship.

The child-parent consent is not to conduct assessments and/or counselling for court purposes.

BENEFITS AND RISKS OF THERAPY
As with any powerful treatment, there are both benefits and risks. The benefits of receiving child-parent psychotherapy services is to help parents work together to meet their child’s physical, emotional and social needs, to increase their knowledge and skills around parenting, enhance the quality of their parent-child attachment relationships, and reduce feelings of distress.

The risks are that therapy requires a time commitment, effort and intention. As well, parents may feel uncomfortable answering questions about sensitive matters. I will aim to provide the most effective therapy services based on my understanding of your specific situation, available research, and current standards of best practice.

CONFIDENTIALITY AND LIMITS TO CONFIDENTIALITY
If I am seeing the child on their own, they will be informed that I will not disclose details that they would like kept private. However, I will help to support the child share their thoughts, feelings and concerns with their parents to improve their relationship.

I am required by law and the guidelines of my social work profession, to disclose information whether or not I have permission from the parent(s) and/or legal guardian(s). These situations include:
• Abuse/Neglect: If I have reason to believe that a child or vulnerable adult is in need of protection due to abuse and/or neglect.
• Risk of harm to self/other: If I have reason to believe that someone plans to cause serious harm or death to themselves or someone else, and Ms. Sather is concerned that the person has the ability to do so in the near future.
• Court-order subpoena: If a court orders that information and reports on file be released to the court.
• Risky driving: If a person has a condition that makes it dangerous to drive and s/he continues driving despite knowing the risks.
• Professional misconduct: If I learn about the behavior of another health professional that is inappropriate and/or might cause danger to someone.

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.

PARENT(s) ELECTION TO WITHDRAW
Parent(s) have the right to withdraw from the child-parent psychotherapy services, at any time. However, parents are encouraged to share any concerns, and/or questions about services, fees, or procedures working as a Therapist, so that we may successfully resolve them. If they cannot be resolved, referrals will be made to another Therapist.
My services will be rendered in a professional manner consistent with the code of ethics and standards of practice, as described by the British Columbia College of Social Workers. If at any time, for any reason you are dissatisfied with my services, please let me know. If I am not able to resolve your concerns, you may report your complaint in writing to the British Columbia College of Social Workers at #302 – 1705 West 8th Avenue, Vancouver, BC V6J 5C6.
WITHDRAWAL OF THERAPIST
As a Therapist, I reserve the right to withdraw services for any reason and agree to provide written notice of withdrawal. In the event that I withdraw, I will make every effort to provide a referral to another Therapist.

SESSION FEE & LENGTH
Fees are $120.00 for 60 minutes. Initial session is $160.00 for 90 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 Safety Plan.

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 midday or and 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.

PARENTS ACKNOWLEDGEMENT AND INFORMED CONSENT
By signing below, we are indicating that we have been made aware of the benefits, risks, and the limits to confidentiality. We acknowledge that we have had the opportunity to carefully read this document and to ask, and to have answered, any questions or concerns. We acknowledge that we understand the information contained in this document.
Our signatures indicate that we are giving consent for Dawn Sather of Sather Child Counseling & Consulting Inc. to provide counseling with us and our minor child(ren) that we bring to therapy.

Thank you for the opportunity to provide clinical counseling services.

Kindly,

Dawn Sather, MSW., RSW., RSW.

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