Dawn Ingall, dip.couns. dip.psych.
Provisional Member of NZAC
Free phone: 0800 2 BEGIN (223446)
COUNSELLING INFORMATION DISCLOSURE STATEMENT
Counselling is a relationship that works in part because of clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to change.
As a client in counselling, you have certain rights that are important for you to know about because this is your therapy whose goal is your well-being. There are also certain limitations to those rights that you should be aware of.
As a counsellor, I have corresponding responsibilities to you.
My Responsibilities to You as a Counsellor
I. Confidentiality:
With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior written permission.
I will always act so as to protect your privacy even if you do release me in writing to share information about you.
You may direct me to share information with whomever you chose, and you can change your mind and revoke that written permission at any time.
Should you elect to communicate with me by email in our work together, please be aware that email is not completely confidential. All emails are retained in the logs of your or my Internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. Any email I receive from you, and any responses that I send to you, will be printed out and kept in your treatment record.
The following are ethical or legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect.
1. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.
2. If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child, Youth and Family Services within 48 hours and an Adult Protective Services or police immediately.
3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the CATT (Crisis Assessment & Treatment Team) and police. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call them.
4. If you tell me of the behaviour of another named health or mental health care provider that informs me that this person has either a. engaged in sexual contact with a patient, including yourself or b. is impaired from practice in some manner by cognitive, emotional, behavioural, or health problems, my ethical responsibility requires me to report this to their licensing board. I would inform you before taking this step.
The next is not a legal exception to your confidentiality. However, it is a policy you should be aware of if you are in couple’s therapy with me.
If you and your partner decide to have some individual sessions as part of the couples therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. Do not tell me anything you wish kept secret from your partner. I will remind you of this policy before beginning such individual sessions.
My Approach to Therapy:
I may use a variety of techniques in therapy, trying to find what will work best for you. These techniques are likely to include dialogue, interpretation, cognitive reframing, awareness exercises, self-monitoring experiments, visualisation, journal keeping, drawing, and reading books. If I propose a specific technique that may have special risks attached, I will inform you of that, and discuss with you the risks and benefits of what I am suggesting.
I may suggest that you consult with a physical health care provider regarding somatic treatments that could help your problems; I refer both to traditional and non-traditional (homeopathic and Oriental medicine) practitioners, and will be glad to discuss with you the pros and cons of various alternatives.
I may suggest that you get involved in a therapy or support group as part of your work with me. If another health care person is working with you, I will need a release of information from you so that I can communicate freely with that person about your care. You have the right to refuse anything that I suggest.
I do not have social or sexual relationships with clients or former clients because it is unethical and illegal.
Therapy also has potential emotional risks. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. Making changes in your beliefs or behaviours can be scary, and sometimes disruptive to the relationships you already have.
You may find your relationship with me to be a source of strong feelings, some of them painful at times. It is important that you consider carefully whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful and I will be happy to discuss these risks further if required.
Record-keeping:
I keep very brief records, noting only that you have contacted me, what interventions happened as a result, and the topics we discussed, you have the right to a copy of your file at any time. You have the right to request that I correct any errors in your file. You have the right to request that I make a copy of your file available to any other health care provider at your written request. I maintain your records in a secure location that cannot be accessed by anyone else.
Other Rights:
You have the right to ask questions about anything that happens in therapy. I'm always willing to discuss how and why I've decided to do what I'm doing, and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns,
and can request that I refer you to someone else if you decide I'm not the right therapist for you. You are free to leave therapy at any time.
General:
You normally will be the one who decides therapy will end, with three exceptions. If we have contracted for a specific short-term piece of work, we will finish therapy at the end of that contract. If I am not in my judgment able to help you, because of the kind of problem you have or because my training and skills are in my judgement not appropriate, I will inform you of this fact and will is desired attempt to refer you to another therapist who may meet your needs.
If you do violence to, threaten either verbally or physically, or harass myself, my office, or anyone associated with me, I reserve the right to terminate you unilaterally and immediately from treatment. If I terminate you from therapy, I will offer you referrals to other sources of care, but cannot guarantee that they will accept you for therapy.
If I am going to be away from the office I will tell you well in advance.
Fees & Scheduling:
Fee to be negotiated prior to commencement and is payable at each session - Sessions are 50-minutes long and usually weekly unless decided otherwise. Cancellation should be made 24hours in advance to avoid being charged.
Client Consent to therapy:
I have read this statement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I understand the limits to confidentiality. I understand my rights and responsibilities as a client, and my therapist's responsibilities to me. I agree to undertake therapy with Dawn Ingall. I know I can end therapy at any time I wish and that I can refuse any requests or suggestions made.
I am over the age of eighteen.
Client Signed:____________________________________Date:________________