Consent form for Inner Orbit Therapy

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NOTE: If any questions arise from this policy, please discuss them with me during our initial consultation call or in session.

Description of the service

Purposes and benefits of therapy

Professional psychotherapy is a safe and confidential collaboration between a qualified counsellor and you. It is designed to promote mental health and well-being, build self-understanding, and provide insight on difficult life situations and concerns.

We all have our own history, perceptions, and expectations and as such the outcome of therapy can vary widely. While I cannot promise any particular outcomes from the therapy process, I am committed to working with you using best counselling practices and adjusting the service to suit your needs.

Risks of therapy

The nature of counselling involves dealing with issues and aspects of your life that could trigger a wide range of emotional responses and reactions. It is important that you keep me informed of any such experiences that come up so that I can support you with them.

Conclusion of services

As the client, you may choose to end services with Inner Orbit Therapy at any time for any reason. No notice is required beyond that specified by the cancellation policy below.

However, ending a therapeutic relationship in a purposeful manner can provide ongoing benefits even after services have been concluded. If you're thinking of discontinuing therapy and feel comfortable sharing this, please notify me so that we can end our relationship on the proper note and honour any work we've done or foundations we may have laid for the future.

Privacy and confidentiality policy

Inner Orbit Therapy takes privacy seriously and is committed to complying with the Australian Privacy Principles in the Privacy Act 1998 (Cth) (the Privacy Act).

Personal information

Personal information is any information about you that can be used to identify you directly or indirectly, such as name, address, phone number, email address, or date of birth.

As part of our service to you, Inner Orbit Therapy needs to collect and record personal information from you. This is a necessary part of your participation in therapy and allows us to provide you with high quality and professional support.

Confidentiality

Any information we collect is stored securely and remains private and confidential. Only people involved in your care will have access to this information and they are subject to the same confidentiality restrictions as laid out on this contract. We will not disclose your personal information to third parties without your consent.

For more information on how we handle your data, see our separate Privacy Policy.

Limits to confidentiality

Legal limitations to confidentiality may require Inner Orbit Therapy to disclose your information to a third party without your consent where:

failure to disclose may, in the reasonable belief of Inner Orbit Therapy, place you or another at serious risk of harm;
a child or young person is at risk; or
a Court of Law instructs Inner Orbit Therapy to disclose your information.

Supervision

I have an ethical responsibility to reflect on my counselling practice. As part of this professional reflection, I may discuss my work with you with my clinical supervisor. In such situations, any information presented will be de-identified and your identity kept anonymous.

Scheduling, cancellations, and billing

Hours of operation

My consulting hours for in-person sessions are between 8:30am - 12:30pm on Wednesdays. I am open for online telehealth appointments between 9am - 3pm on Thursdays and 9am - 5pm on Fridays.

Scheduling sessions

Prior to your first session, I require new clients to undertake a free 15-minute consultation call with me to ensure the service is a good fit for you. After this, you can book appointments directly from my Appointments page up to a month in advance.

Sessions are provided on the understanding that:

we have a confidential and uninterrupted space—for telehealth, this means you should not be driving a vehicle or be in a noisy public place (e.g. a supermarket);
neither party will record sessions without the other’s consent;
both parties will treat each other with respect and dignity;
you will discuss with your therapist ahead of time if you would like someone else to be present during the session. If approved, they will need to fill out a consent form; and
our internet or phone connection is as reliable as possible in the case of telehealth.

If these conditions are not met, the therapist reserves the right to cancel or reschedule the session as required. If you repeatedly miss sessions without calling and don’t respond to our enquiries, we may cease offering services to you.

Fees and billing

15-minute consult calls are provided to new clients interested in my services free of charge, and can be booked online.

The rate for a standard 55 minute counselling session (in-person or online) is $120, payable when booking the session online. This fee may be adjusted at any time, and if I do so, I will give you two weeks' advance notice if you are an existing client. If you require an alternative payment method, please discuss it with me.

Cancellations

If you can’t attend a session, you are required to provide me with at least 24 hours of notice so that we can reschedule. Failure to do so will incur a charge equal to 50% of the session fee if you give at least 3 hours of notice, or 100% of the session fee in the case that you don’t notify me at all and also do not show up to your scheduled session.

If you fail to provide notice and do not attend a session within 10 minutes of its scheduled start time, it will be considered cancelled and no refund will be issued.

If you’re feeling unwell, it may be possible to reschedule the appointment at no extra cost. Please contact me with as much notice as possible to see what we can work out.

Session reminders and confirmation

Inner Orbit Therapy may send you email and SMS text messages for session confirmation or reminder purposes. I endeavour to keep this communication to a minimum. If you would like to opt out of these reminders, please let me know.

Contact policy

Responses to inquiries

My business number is primarily used for scheduling and coordinating appointments. If you have another business inquiry or concern, please direct it to my email address (info@innerorbittherapy.com.au) and I will do my best to respond within 2-3 business days.

To preserve the therapeutic relationship, I will only respond to personal emails at my discretion. However, you are free to introduce or discuss their contents during your therapy session if you wish.

In an emergency

As I do not provide a crisis service, if there is an emergency please contact:

your doctor, or the relevant emergency service on 000;
Lifeline on 13 11 14;
Beyond Blue on 1300 22 4636;
Suicide Call Back Service on 1300 659 467.

Social media

In the interests of privacy and maintaining appropriate professional and ethical boundaries, I will not accept friend/follow or message requests from past or present clients on social media platforms. Any messages sent outside of my business email or website will be left unread and deleted.

Complaints

If you are not happy with the service provided by Inner Orbit Therapy and would like to make a complaint, head to my Complaints page and follow the instructions there, or follow the complaints process on PACFA’s website.

Acceptance by client

I, [client name], have read, understood, and agree to this Consent Form.

[client name] [therapist name]

[client signature] [therapist signature]

[date] [date]