Informed Consent

This is the agreement between you, the client and the therapist from Gracey Psychotherapy that clarifies the standard of our services and regulations for the therapeutic relationship.  When you have finished reading and fully understand the contents of this form, then you may sign it.  

Therapy

Gracey Psychotherapy provides therapy based on an integration of therapeutic methods.  They are brief Solution-Focused therapy, Cognitive Therapy, Behaviour Therapy, Cognitive-Behaviour Therapy, experiential/emotional focused therapy and Family Systems Therapy.

The process of therapy begins with clearly defining your problem. Then you and the therapist will discuss your thoughts and feelings.  You will be required to spend time at home practicing the new skills you have learned in the therapy sessions.  Throughout the therapy, the therapist will provide psychological counselling services that may include: assessment and diagnosis, treatment planning, and behaviour modification plans. The sessions may involve individual and/or group family therapy.  The effectiveness of the therapy depends upon the level of open communication between you and the therapist.  As a client, you have the right to ask your therapist about her qualifications, background and orientation.  If in any way during the therapy you doubt whether the therapy is effective, are unclear about what the therapist has said, or have any other questions, please feel free to bring them to the therapist's attention.

Confidentiality

The details of what has been discussed in therapy will be treated with strict confidentiality.  Information about you will not be shared with anyone without your permission.  However, there may be times when the rules will have to be overridden. These apply to extreme situations in which information must be released, such as in cases of medical emergency; abuse (if you are a victim or perpetrator of child, elder or dependent adult abuse); a perceived threat of harm to yourself, someone else or the property of others; or in cases of neglect; court orders; billing requirements; or whenever legally required.  The records of all information gathered in the course of therapy will be kept according to the guidelines of the American Association of Marriage and Family Therapist/Canadian Registry of Marriage and Family Therapist, B.C. Association of Clinical Counsellors and relevant provincial laws.

Terms of payment

Gracey Psychotherapy charges $90.00 per hour for multiple sessions and $100.00 per one time consultation. You are expected to pay the therapist before each session begins.   Please feel free to tell the therapist any time if you have financial difficulties or trouble meeting the payments.

Counselling in case of emergencies

The therapists from Gracey Psychotherapy may choose not to respond to calls after therapy hours in case of emergencies.  In case of emergencies after business hours, you may choose to contact crisis help lines, or other resources, such as your medical doctor or 911.

Terms of therapy

If you wish to terminate the therapy, you have the right to do so.  Gracey Psychotherapy would prefer you to inform the therapist of the reasons for your decision during a counselling session, even though it is understood that there is no guarantee that the therapy will be beneficial to you.  However, with your feedback, the therapist(s) can check your progress thus far and look for possible ways to modify the therapy so that it is more suitable to you.  It is also understood that the therapist may terminate provision of service to you if you are not complying with instructions from the therapist, as the therapy requires you to do your part in order to make the therapy beneficial to you.

Gracey Psychotherapy is ethically required to provide therapy to you so long as it is beneficial to you. If the progress of your sessions proves ineffective, the therapist will discuss the situation with you so that together you can find alternative solutions, such as an appropriate referral to some other therapists or agencies.

I have read, understand and agree to the information and the policies of Gracey Psychotherapy as described in this Informed Consent form.

Client  _____________________ (print name)  ____________________(sign)

Date   _____________________

Therapist ___________________ (print name) ____________________(sign)

Date   ______________________