Walk and Talk
Counselling Informed Consent Form
Please print this page and either email it to: [email protected] before your first consultation or please bring it with you to your initial counselling session. Thank you!
The client may ask questions on what to expect during and end result of the therapy.
The client may decline to proceed the therapy as to the techniques which may be conducted by the therapist.
The client may cease to continue therapy anytime, without any impediment and may return to therapy anytime.
The therapist has the right to dismiss the client from the course of therapy.
The client has the right to review his or her records from the therapist.
Right to confidentiality
Within limits provided for by law, all records and information acquired by the therapist shall be kept strictly confidential in accordance with the principles and guidelines of ACA and PACFA's professional standards. All information will not be shared or revealed to any person, agency, or organization without the prior written consent of the client. Although according to the harm principle, if there is a situation where there is domestic violence, self-harm or harm for others, the therapist has the right to contact the necessary institutions.
If client has a particular concern needing a specialized treatment approach (e.g. a couples therapy, EMDR therapy, family therapy, sex therapy, alcohol or drug problems specialist etc.), the therapist can refer the client to another specialist in the field.
Anonymous supervision will be carried out with therapist's supervisor.
Please check the items that you believe is affecting you:
Anger or hostile feelings ______
Anxiety and fears ______
Sadness or Low Mood ______
Family issues ______
Physical distress ______
Relationship/Marital concerns ______
Traumatic experiences ______
Social conflicts ______
Suicidal thoughts ______
Stress and nervousness ______
Self-esteem or confidence ______
Work or career concerns ______
Sexual Concerns ______
I have reviewed this agreement. I understand my rights as a client.
I accept this agreement and consent to counselling with the afore mentioned guidelines and procedures.
First Name ______________________________________________________
Last Name ______________________________________________________
Client Signature __________________________________________________
Date Signed _____________________________________________________