Information And Consent Form For Sessions - Natalia Irodova

Information And Consent Form For Sessions

The Mentor:

Natalia Irodova, a mentor practising in Limassol, Cyprus having her office at Leontiou Machaira 75, Indigo Centre, Office 302, 3025, Limassol, Cyprus (hereinafter referred to as the ‘‘The Mentor’’ for the purposes and terms of this Form). The Mentor is a graduate of Bsc Psychology and Combined Studies in London Metropolitan University and has been practising as a mentor in Cyprus since 2016.

The Client:

…………………………………………………….., of ……………………………………………………………….., tel: …………………………. (hereinafter referred to as the ‘‘The Client’’ for the purposes and terms of this Form). The Client wishes to attend a number of one-to-one sessions with the Mentor (hereinafter referred to as the ‘‘The Sessions’’ collectively for the purposes and terms of this Form).

The Client has certain rights that are important for him to know about because this is his therapy, and the goal is the Client’s well-being. There are also certain limitations to those rights that the Client should be aware of. The Mentor also has corresponding responsibilities to the Client.

Confidentiality:

With the exception of certain specific exceptions described below, the Client has the absolute right to the confidentiality of his therapy. Both Parties agree that at no time during the Sessions or in the future, will they disclose directly or indirectly to any third party any confidential information or knowledge about each other. The Mentor cannot and will not tell anyone else what the Client has told him, or even that the Client is in therapy, without the Client’s prior written permission.

The Mentor may legally speak to another health provider or a member of the Client’s family about the Client without the Client’s prior consent, but she will not do so unless the situation is an emergency.

If the Mentor is required to discuss her work with a qualified colleague, she can do that; however, the Client will not be identified in such discussions.

The Mentor will always act so as to protect the Client’s privacy, even if she is released in writing to share information about the Client. The Client may direct the Mentor to share information with whomever the Client chooses, and the Client may change his mind and revoke that permission at any time.

The Client may request anyone he wishes to attend a therapy Session with him.

If the Client wishes to communicate with the Mentor by email at some point in their work together, he is aware that emails are not completely confidential. Any emails received by the Mentor and any responses that she sends back to the Client, will be printed out and kept in the Client’s treatment record.

Material from counselling Sessions shall remain in the client record and should never normally be revealed publicly unless both Client and Mentor agree.

All information disclosed within Sessions and the written or recorded records pertaining to those Sessions are confidential and may not be revealed to anyone without the Client’s written permission, except where disclosure is required by law or if there is significant risk of harm to others or if there are concerns about the safety of a child or vulnerable adult.

Examples of when disclosure is ethically or legally required:

  • Where there is a reasonable suspicion that the Client will harm another person, the Mentor must attempt to inform an appropriate authority in order to protect the intended victim.
  • Where there is a reasonable suspicion of child, dependent or elder abuse or neglect, and where a Client presents a danger to self, to others or to property.
  • If the Mentor believes that the Client is in imminent danger of harming himself, the Mentor may legally break confidentiality and inform an appropriate authority. The Mentor is not obliged to do this, and would explore all other options with the Client before she takes this step. If at that point the Client is not willing to take steps to guarantee his safety, the Mentor will inform the appropriate authority (i.e. police, hospital, etc.).
  • If the Client is younger than 18 and he informs the Mentor that he is having sex with an adult, or with a teacher, the Mentor has to report this. The Mentor will inform the Client before taking this action.
  • If the Client is involved in a custody dispute, for example, or if he places his mental status at issue in litigation initiated by him, the defendant may have the right to obtain the counselling records and/or testimony of the Mentor.
  • In couple and family counselling, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. The Mentor will use judgment when revealing such information. The Mentor will not release records to any outside party unless she is authorized to do so by all adult family members who were part of the treatment.
  • If a third party (i.e. insurance company) is paying for the bill of the Sessions, the Mentor is normally required to give a diagnosis to that third party in order to be paid.

Harm to Self or Others:

If there is an emergency during the work with the Mentor, or in the future after termination, in which the Mentor becomes concerned about the Client’s personal safety, concerned about the possibility of the Client injuring someone else, or concerned about the Client receiving proper psychiatric or medical care, the Mentor will do whatever she can within the limits of the law, to prevent the Client from injuring himself or others and to ensure that he receives the proper care. For this purpose, the Mentor may also contact the police, hospital or an emergency contact whose name the Client has provided. This is, however, very rare and in any circumstances like these, the Mentor will make every reasonable effort to discuss the situation with the Client first.

Litigation Limitation:

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 the Client nor his legal representative, nor anyone else acting on behalf of the Client will call on the Mentor to testify in court or at any other proceedings, nor will a disclosure of the counselling records be requested.

Record Keeping:

The Mentor will keep very brief records, noting only that the Client has attended Sessions, what interventions happened in Session, and the topics discussed. If the Client prefers that the Mentor keeps no records, he must give the Mentor a written request to this effect for the Client’s file and the Mentor will only note that the Client attended the Session in the record.

The Client has the right to request a copy of his file at any time. He can also ask the Mentor to correct any errors in his file. The Client has the right to request that the Mentor makes a copy of his file available to any other health care provider at the Client’s written consent.

The Mentor maintains the Client’s records in a secure location that cannot easily be accessed by anyone else.

Other Rights:

The Client has the right to ask questions about anything that happens during the Sessions. The Mentor should be willing to look at alternatives that might work better for the Client. The Client can ask the Mentor to try something that he thinks will be helpful. The Client is not obliged to follow the advise of the Mentor or act in any way with which he does not feel comfortable. The advise of the Mentor is simply for guiding purposes and the Client is always free to act in any way he prefers or leave therapy at any time.

The Mentor’s Approach to Therapy:

The Mentor will use a variety of techniques during the Sessions in order to figure what will work best on the Client. These techniques are likely to include dialogue, interpretation, cognitive reframing, awareness exercises, visualisation, journalkeeping, drawing, reading books, and any other psychology exercises that have been chosen by the Mentor, etc.

Therapy also has potential emotional risks. Approaching feelings or thoughts that the Client has tried not to think about for a long time may be painful. Making changes in the Client’s beliefs or behaviours can be scary, and sometimes disruptive to the relationships he already has. It is important for the Client to consider carefully whether these risks are worth the benefits to himself of changing. Most people who take the risks find that therapy sessions are helpful.

The Client is normally the one who decides sessions will end, with 2 exceptions:

  • If the Mentor decides that she cannot help the Client because of the kind of problem he has or because her training and skills are not appropriate.
  • If the Client threatens or uses violence against the Mentor, her office, her family, etc.

The Client’s Responsibilities as a Therapy Client:

The Client must come to his Session on the time scheduled. Sessions last for 1 hour and if the Client is late, the Session will still end on time and not run over into the next client’s session. If the Client misses a Session without cancelling 24 hours before, he must pay for that Session.

The Client is responsible for paying for his Sessions everytime he has a session by cash.  If the Session is longer than 1 hour, the Mentor will bill the Client prorated on the hourly fee. Emergency calls of less than 10 minutes are normally free. However, if the Parties spend more than 10 minutes on the phone, or on sending each other emails, the Mentor has a right to bill the Client.

Governing Law and Jurisdiction:

This consent will be governed by the laws of the Republic of Cyprus. The Client irrevocably agrees to submit to the exclusive jurisdiction of the Courts of Cyprus.

 

Complaints:

If the Client is unhappy with the Sessions or with the Mentor’s willingness to listen and respond, he must talk to the Mentor so that she can respond to his concerns and try to solve the problem.

Both Parties for the purpose of the Sessions and in the future, will not act in any way that may cause damage to the interests, name, clientele or business of the other party.

CLIENT’S CONSENT TO THE SESSIONS:

I have read this form, 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 required by law and I understand that I am expected to keep communications confidential and that all records of communication between the Mentor and myself remain the property of the Mentor. I consent to the release of information necessary to complete the billing process. I agree to pay the fee that was prio agreed orally with the Mentor. I understand my rights and responsibilities as the Client, and the Mentor’s responsibilities to me. I agree to undertake therapy with Natalia Irodova (the Mentor). I know I can end therapy at any time I wish and that I can refuse any requests or suggestions made by the Mentor. I am over the age of 18. This is an indefinite consent.

Dated: ………………………………………….

Signed: …………………………………………