Consent for Clinical Counselling Treatment

ADULT / CHILD / YOUTH (First & Last Name):

Date of Birth:

Driver Licence:

Address/Email/Phone:

LEGAL GUARDIAN (S)

Names:

I, _____________, agree that Suzana Dujmic has talked to me about informed consent and answered my questions. 

I, _________________, give my informed consent to participate in the clinical counselling as discussed with the clinician. This consent may be withdrawn at any time by telling the counsellor. 

Confidentiality is key to the effectiveness of the counselling process, so the personal information you share in counselling will be kept confidential. Confidentiality continues after the end of the counselling relationship. However, there are some instances (exceptions) when confidentiality will not apply: 

A/ If a child is or may be at risk of abuse or neglect, or in need of protection; 

B/ If a counsellor believes that you or another person is at clear risk of imminent harm; 

C/ For the purposes of complying with a legal order such as a subpoena, or if the disclosure is otherwise required or authorized by law. 

I may also disclose information for the purpose of a professional consultation, in which case your identity will remain confidential. For any other purposes not outlined here, you will be requested to sign an additional disclosure form. 

I, _________________, do not have open Family Service, Child Service file or recent history with the Ministry of Children and Family Development (MCFD) in British Columbia. If there is a change in these circumstances, I will inform this counsellor immediately. This counsellor may terminate the treatment and refer me elsewhere. 

I, ____________________, agree to cover the cost of clinical counselling ($130 individual or $180 couple/family) session in the length of 55 min or 90 for initial and/or family session at the end of each session in the form of cash, check, direct/credit card payment. Cost of home and/or collateral visits/phone calls will be discussed and/or charged separately. Cancellation of any session need to be done 24 hours in advance. Multiple missed appointments may result in termination of the service by the clinical counsellor. 

I, ____________________, consent to remote counselling using video or phone platforms that are offered by the counsellor and are in compliance with Canadian Personal Information Protection Act. 

I, Suzana Dujmic MC RCC, adhere to provide a safe and supportive environment where you will feel heard and where you have a choice of receiving counselling in the modality of your preference that may best address your needs and desires. If we have different views about the modality proposed by you and a satisfactory agreement is not made, necessary referrals will be made. 

If you have a concern about any aspect of your counselling, you are requested to first address it to myself, Suzana Dujmic, RCC. If you find it to be impossible or unsafe, or if your concern is not resolved through collaborative discussion process, you may contact the Register of the BC Association of Clinical Counsellors at 1-800-909-6303.