Please read through the following information carefully.
I hereby give consent that I will willingly participate in therapy. I further acknowledge that Donna Mitchell must obtain my informed consent before changing or altering the nature of the intervention or psychological service(s) that we agree upon.
Confidentiality and Limits on Confidentiality
What I share with Donna is treated as confidential. Confidentiality includes Donna’s supervisor (another experienced therapist who helps to ensure that Donna is working as well as she can be).
The only time Donna may need to break confidentiality is if she is concerned about harm to myself or to someone else. Donna would talk to me about this first though, if at all possible.
I am aware that the law limits the confidential nature of the psychological service(s) provided to me. Typically these limits on confidentiality may arise if Donna perceives that there is a risk of harm in a situation such as the following:
1. If I am an imminent danger to myself, or present a danger to others or report that my life is threatened by someone, the law requires that steps be taken to prevent such harm.
2. If a court orders the disclosure of records.
3. Guidelines of confidentiality and limits on confidentiality do not apply to psycho-legal work as reports are requested by courts and law practitioners.
Furthermore, I understand that it is my responsibility to ensure that the room in which I sit for the duration of the online session is private.
I also understand that online therapy is not appropriate for a crisis situation. In such a situation I can rather contact an in-person therapist or use these resources.
Protocol for interrupted Internet signal
I understand that there may be times where the internet signal may be interrupted and that this will inevitably effect the therapy session. During such a time I understand and accept to adhere to the following protocol:
If the video produces a static image we will try to continue the conversation without video. If, after we have tried to fix the internet problem, we are unable to resolve the internet connection difficulty I will have my cellphone available to receive a phone call from Donna to continue the session.
If for whatever reason I am unable to receive a phone call from Donna, I understand that I can write down what I wanted to discuss in an e-mail (no longer than 10 pages) and Donna will respond to this with
an e-mail in less than 24 hours. Alternatively Donna and I will discuss rescheduling the session.
I take note that the practice of Talk Feel Change does not claim, on my behalf, from medial aids and does not adhere to medical aid fees. I understand that I remain personally responsible for the payment of my therapy sessions.
If I choose to cancel or reschedule a session, I will let Donna know via e-mail at least 48 hours in advance. I acknowledge that if I fail to do so I will be held responsible for the payment of that session.
I understand that I am expected to pay in full even if the Internet connection was interrupted and we had to speak on the phone or through an e-mail.
If it is Donna who asks to cancel or re-schedule a session (this would only be in an emergency), she will also try to give me 48 hours notice. Any session that has been cancelled by Donna will be rescheduled or refunded.
Donna is registered with the ICO (Information Commissioner’s Office) and works in line with General Data Protection Regulation (GDPR) – UK data protection law.
The data she needs to store for us to work together are my contact details, session notes and any emails between us. This is so that she may communicate with me regarding appointments, invoicing, or in an emergency. Donna does not share this data with anyone else; and she keeps this information for 7 years after therapy ends.
Length of Sessions
All therapy sessions conform to the standard 50 minutes, as this allows for 10 minutes of session note making. Usually we will meet on a weekly basis at a regular time.
Duration of Therapy
I understand that there is no obligation to work together for any set period of time. Donna and I will work together and on a continual basis and she will send me links to payment until we reach a point where we agree that therapy is no longer needed. I am aware that Donna believes that I know best how much I want to work on at this time and how involved that might be. I know that it is in the benefit of my therapeutic process to talk with Donna in advance about ending therapy.
Donna will assume we are working to this agreement from our first contact unless we discuss/agree otherwise.