To be signed and returned to me only if you wish to continue after the first session
AGREEMENT FOR PSYCHOTHERAPY SERVICES CONDUCTED BY Geoff T Cox MA MBACP (Accred)
The process of therapy/evaluation
Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits requires effort on your part. Psychotherapy requires your very active involvement, honesty and openness in order to change your thoughts, feelings and/or behaviour.
During evaluation or therapy, remembering or talking about unpleasant events, feelings or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel upset, angry, depressed, challenged or disappointed.
- Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended.
- Psychotherapy may result in decisions about changing behaviours, employment, substance use, schooling, housing or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member.
- Change will sometimes happen quickly, but more often it will take time and patience on your part. There is no guarantee that psychotherapy will yield positive or intended results.
Discussion of the Therapeutic Approach
During the first session and throughout this process, I will discuss with you your understanding of the issue/problem, therapeutic approach and objectives and your view of the possible outcomes of treatment. If you have unanswered questions about any aspects of the process during the course of your therapy, their possible risks, my expertise in employing them or about the therapeutic plan, please ask and you will be answered fully. You also have the right to ask about other possible therapies and their risks and benefits. If you could benefit from any treatment that I do not provide, I have an ethical obligation to assist you in obtaining those treatments.
Dual Therapeutic Relationships
Not all dual relationships are unethical or avoidable. However, sexual involvement between therapist and client is never part of the therapy process, nor are any other actions or dual relationship situations that might impair my objectivity, clinical judgment, or therapeutic effectiveness or that could be exploitative in nature. In addition, I will never acknowledge working therapeutically with anyone without his/her written permission. In some instances, even with permission, I will preserve the integrity of our working relationship. For this reason I will not accept any invitations via social networking sites nor will I respond to blogs written by clients or accept comments on my blog from clients which relate to therapy sessions or the therapeutic relationship.
During the initial intake process and the first couple of sessions, I will assess if I can be of benefit to you. If you have requested online counselling, my assessment will include your suitability for psychotherapy delivered via technology. I do not accept clients who, in my opinion, I cannot help. In such a case, I will give you a number of referrals that you may contact. If at any point during psychotherapy, I assess that I am not effective in helping you reach your therapeutic goals, I am obliged to discuss this with you, up to and including termination of treatment. In such a case, I would give you a number of referrals that may be of help to you. If you request and authorize in writing, I will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified and, if I have your written consent, will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, I will offer to provide you with names of other qualified professionals whose services you might prefer.
N.B. It is not appropriate or advisable to consult more than one psychotherapist/counsellor at any one time.
Privacy and Confidentiality
All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. Likewise, you are expected to keep our communications confidential and you understand that all records of communication between client and therapist remain the property of Geoff T Cox.
When Disclosure May be Required:
Disclosure may be required pursuant to a legal proceeding. If you are involved in a custody dispute or if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by me. In couples and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. I will use my clinical judgment when revealing such information. I will not release records to any outside party unless I am authorized to do so by all adult family members who were part of the treatment or unless compelled to do so by law or a valid court order.
If a request for disclosure were to be made to me other than by Court Order then I would write to the (former) client for their consent to disclosure to the third party and you could levy a reasonable fee for copying any such documents. For this service there would be an administration fee of £50.
Harm to Self or Others:
Disclosure may be required if I become concerned about your personal safety and/or the possibility of you injuring someone. For this purpose, I may also contact law enforcement, your GP, hospital or an emergency contact whose name you have provided.
Confidentiality of E-mail and Fax Communication:
Therapeutic email exchanges are delivered via HushMail. You agree to work with me online using HushMail. If you choose to email me from your personal email account, please limit the contents to housekeeping issues such as cancellation or change in contact information. I will not respond to personal and clinical concerns via regular email. If you call me, please be aware that unless we are both on land line phones, the conversation is not confidential. Likewise, text messages are not confidential. If you send a fax to me, my fax line is in a secure location. Any computer files referencing our communication are maintained using secure and encrypted measures. If you wish to use email as a way to “journal” information between sessions, you understand that I may not have the opportunity to review your journal emails until our next scheduled session. You understand that emails between sessions that contain confidential information will be sent utilising encryption.
I make every effort to keep all information confidential. Likewise, if we are working online together, I ask that you determine who has access to your computer and electronic information from your location. This would include family members, co-workers, supervisors and friends. I encourage you to only communicate through a computer that you know is safe, i.e. wherein confidentiality can be ensured. Be sure to fully exit all online counselling sessions and emails. If we are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within 10 minutes. If reconnection is not possible, email or text to schedule a new session time.
Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your lawyer/solicitor, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
I consult regularly with my clinical supervisor and occasionally with other professionals regarding my clients; however, the client’s name or other identifying information is never disclosed. The client’s identity remains completely anonymous and confidentiality is fully maintained.
* Considering all of the above exclusions, if it is still appropriate, upon your request, I will release information to any agency/person you specify unless I conclude that releasing such information might be harmful in any way.
Telephone and Emergency Procedures
If you need to speak with me between sessions to alert me of an emergency, please call 01562 852145 or 07949 326972 . Your call will be returned as soon as possible. Messages are checked daily (but never during the night time). Messages are checked less frequently on weekends and holidays. If an emergency situation arises that requires immediate attention, you may call the Samaritans at 08457 90 90 90 (http://www.samaritans.org/ – email: email@example.com ) or dial 999. If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 999 or go to a hospital emergency department.
Therapeutic email exchanges can be purchased one at a time or as a package. Payments via credit or debit card can be processed through PayPal.
Current rates for therapeutic services are posted in the Getting Started and Rates section.
Since scheduling of a face-to-face appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for re-scheduling or cancelling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification.
You as the client understand that email sessions have limitations compared to in-person sessions, among those being the lack of “personal” face-to-face interactions, and the lack of visual and audio cues in the therapy process. You understand that online psychotherapy with me is not a substitute for medication under the care of a psychiatrist or doctor. You understand that online therapy is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts. As stated previously, if a life-threatening crisis should occur, you agree to contact a crisis hotline, call 999, or go to a hospital emergency room. You also understand that I follow the laws and professional regulations of the United Kingdom and the psychotherapy treatment will be considered to take place in the UK. I abide by the BACP Ethical Framework for Good Practice in Counselling and Psychotherapy.
Adding your name below indicates that you have reviewed the information available on my website and have read and understand this Informed Consent.
We will discuss this Informed Consent during our first session. Please email this form to firstname.lastname@example.org by clicking on the ‘Submit Form’ button.