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
I am aware that all communication with me and all records relating to the provision of
psychological services to me are confidential and may not be disclosed without written informed consent.
I am aware that the law limits the confidential nature of the psychological service(s) provided to me. I have been advised that typically these limits on confidentiality may arise if Donna Mitchell 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.
I take note that the practice of Donna Mitchell 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 account.
If I choose to cancel a session, I will let Donna know via e-mail at least 24 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.