Informed Consent Form for Counselling

Please read the information (on the right) and then complete the Indemnity Form below.

You will be prompted to sign the form digitally before submitting the form. If you are signing-up for f-2-f counselling, you will also be asked to sign a copy in session.

For online e-therapy please take note of the Additional Information Concerning Online Therapy (E-mail, Chat, and Video). 

 

Indemnity Form

Please first Login to the Paraklesis Members Area or Register as a New user (login/Register Icon top right of page). Then return and complete the form.

Informed Consent Information
  1. Paraklesis Counselling offers professional counselling therapy for individuals, couples and families - specialising in helping people with medication related counselling issues.
  2. Counselling is done from an integrative approach, recognising the importance of biological (medical, pharmacological), psychological (emotions, cognition and behaviour), social (family and community), and spiritual (faith and religion) factors. I specialise in medication related counselling issues.
  3. I am a psychopharmacologist and professional counselling therapist (psychotherapist and marriage/family counsellor). I am a psychotherapist, pharmacist, and professor of counselling psychology (retired), and not a psychologist - if you rather want to see a psychologist, a referral can be made.
  4. I fully adhere to the professional ethical standards of Counselling Psychology Practice.
  5. I will keep the strictest confidence. Your personal and counselling information will be stored in a safe manner. No information will be made available to anyone without your permission (you can review the Paraklesis Confidentiality and Privacy Policy ). Please note that individual face-to-face counselling guarantees confidentiality, but there are limitations to confidentiality in couples, group, family counselling, and online therapy.
  6. Duty to warn: I have a professional responsibility and duty to inform the applicable people/body and take appropriate action, if you indicate that you are going to harm yourself or someone else. If I believe that a child, an older person, or a person with a disability is being abused, I must file a report with the appropriate provincial/state agency.
  7. Your personal values and norms will be respected and I will not force my own values on you. You are responsible for your own growth and the application of the counselling in your own life. Although I recommend that you continue with the counselling until you have reached your goals, you are free to stop the counselling at any time, or to ask for a referral.
  8. Fees and Payment: Fees, including all applicable taxes are payable at f-2-f sessions or before each online session.
  9. Age of Consent: You must be 18 or older to consent to counselling (Parents/guardians of minors must please contact me personally)
  10. If you feel uncertain in any way about the counselling, you are free to address the issues in your first session or e-mail me.

 

Dr Mervin Van der Spuy

Additional Information Concerning Online E-Therapy

  1. Individual face-to-face counselling guarantees confidentiality but there are limitations to confidentiality in couples, group, family counselling, and online therapy.
  2. Please do not make your username and password available to anyone and ensure that the computer and/storage device you use is password protected. The security of e-mail, chat and video counselling is determined and limited by the service provider’s security. Paraklesis does not warrant the privacy of confidential material that becomes insecure because of user negligence.
  3. Personal Identity: In all communications with Paraklesis Counselling, you must agree to honestly represent your identity and personal information. You must not claim to be anyone other than yourself.
  4. Age: If you are a minor (under the age of 18 years) or if a legal guardian has been appointed to represent you, you must obtain parental/guardian consent before counselling can commence.
  5. Location of Services: You must agree that the counselling services provided by Paraklesis Counselling shall be considered, for all legal purposes, to take place in Canada only. Any claims against Paraklesis Counselling which give rise to suits or judicial proceedings must be filed and tried only within Canada in the province of Alberta, and not in the United States of America or any other jurisdiction. Solely the substantive law of Canada, not including its choice of law provisions, will govern any such dispute.
  6. Limitations to Online Counselling: Online counselling cannot be considered the same kind of service as traditional face-to-face therapy. It is counselling delivered from a distance and with time delays. Therefore, you must agree to assume full responsibility for, and control of your treatment and take responsibility for making treatment decisions.
  7. Crises and Emergencies: Because of the limitations of online counselling Paraklesis cannot be held responsible for helping you manage a crisis. If you experience an emotional crisis (intense feelings of distress, emergency or life threatening situation, or any other crisis) during the course of your online counselling, you must manage the crisis by using resources other than those offered by Paraklesis Counselling online. Please review the Paraklesis Safety Plan and Emergency Contingency.

Fees and Payment:

Face-2-Face Therapy: Fees, including all applicable taxes are payable cash, cheque, or Credit Card at each session.

Online E-Therapy: Fees, including all applicable taxes and must be pre-paid online through secure PayPal or Credit Card for all e-therapy.    

Paraklesis Disclaimer

E-Therapy content, linked and posted website articles, and Paraklesis courses are intended for educational purposes and for people who are in treatment with a medical or mental health professional. None of these are designed to help you solve mental health problems on your own or make decisions about your medications on your own.

Please consult with your family physician or psychiatrist concerning your medication before stopping, starting or changing your medication regimen.