Consent-Individual-therapy | Ezra Cake Psychotherapy

Informed Consent
for Individual Therapy

The purpose of page is to explain the rights, risks, limitations and responsibilities involved in the therapy process, please use the toggles to access detailed information.

Informed Consent

As a client of Shauna Cake I understand that therapy has benefits that can include, but are not limited to, gaining skills to ease emotional distress and disturbing thoughts, addressing relationship issues with myself and others. I understand that through therapy I may start to feel a greater sense of agency and resilience. I also understand that in the course of therapy I may experience difficult emotions and thoughts both in and outside of therapy sessions. I understand that there are risks, as well as benefits, to therapy: e.g. that despite the my best intentions, and the best intentions of my therapist, it’s possible my condition might not improve and could even worsen in therapy.

Given the above potential benefits and risks, I understand that I need to discuss my emotional states, sense of progress, and treatment with my therapist in an ongoing fashion in order to make adjustments to the therapy, to end therapy, and/or to consider alternatives to therapy if/when necessary.

As a client of Shauna Cake I understand that I have the following rights with respect to therapy:

Professional Qualifications

I understand that Shauna Cake is a Registered Psychotherapist with The College of Registered Psychotherapists of Ontario and the Canadian Association of Psychodynamic Therapy, as such Shauna Cake is subject to the code of ethics of these professional organizations.

Methodologies

I understand that Shauna Cake draws on a wide variety of therapeutic techniques, including Gestalt Therapy, Mindfulness, Mediation, Art Therapy, Emotion Focused Therapy, Sex Therapy and body-awareness/trauma-informed approaches (Sensorimotor Psychotherapy). Shauna will sometimes suggest exercises based in particular methodologies. I understand that I have the right to withhold or withdraw consent at any time to all or part of the work with Shauna Cake without affecting my right to future care or treatment with Shauna.

Scope of Practice

Shauna Cake is not an acute mental health crises intervention worker. In the event of a medical emergency or an emergency involving a threat to my safety or the safety of others I understand that I should call 911 to request emergency assistance or utilize crises intervention resources as appropriate. The following resources are available in Toronto to assist individuals who are in crisis:

Crisis Hotline: 1-800-448-3000
Suicide & Distress Centre (Toronto) 416-408-HELP (4357)
Gerstein Centre (Toronto) 416-929-5200
Lesbian, Gay, Bi Youth Hotline 1-800-268-9688
Assaulted Women’s Helpline 416-863-0511, 1-866-863-0511
Parent Help Line 1-888-603-9100

Confidentiality

The information I disclose during the course of my therapy is confidential. However, there are exceptions to confidentiality in which Shauna Cake has a duty to report to various agencies and authorities, including, but not limited to:

- - - reporting child, elder, and dependent-adult abuse
    - reporting expressed threats of violence towards a victim
    - intervening in an imminent suicide attempt
    - responding to a legal subpoena or To facilitate an investigation or inspection if authorized by warrant or by any provincial or federal law
    - For the purpose of contacting the emergency contact provided by you if you become ill, injured or incapacitated and unable to give consent personally during a session.
    - To a College for the purpose of administration or enforcement of the Regulated Health Professions Act, 1991 (RHPA) (e.g. assessment of Shauna Cake’s practice as part of the quality assurance program or mandatory reporting where you are a regulated health professional and Shauna Cake has reasonable grounds to believe that you have sexually abused your patient/client)
    - a health care provider sexually abusing you

In addition, I understand that Shauna Cake may discuss some confidential material as part of professional consultation, as is consistent with professional protocols.

If I ask Shauna Cake to speak to another healthcare provider about anything related to my work with Shauna, I will be asked to signed a consent form first that describes my acceptance and limits of what Shauna can disclose.

Communication

Telephone consultations between office visits can be negotiated. Shauna will attempt to keep those contacts brief due to the belief that important issues are better addressed within regularly scheduled sessions. Shauna will attempt to provide timely response to client contacts Monday through Friday 9 am – 6 pm. I understand that if I convey content related to my therapy sessions via email, text or social media this can compromise my confidentiality.

Documentation

I understand that I have a right to access my file and copies of records upon my request, subject to reasonable notice.
I have a right to a receipt for therapy services upon my request, subject to reasonable notice.

Search Engines, Social Media and Technology

It is not a regular part of Shauna Cake’s Psychotherapy practice to search for me on search engines or social media. In rare exceptions such as during a crises an Internet search may be made, in the event of this circumstance occurring the search would be fully documented and discussed with me during my next appointment. I understand that Shauna Cake does not accept “friend” requests from current or former clients, or family members of clients, on Facebook or other similar social networking sites.

I may find Shauna Cake Psychotherapy on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses but I understand that Shauna Cake does not request testimonials, ratings, or endorsement. Shauna does not consult these sites therefore they are not an effective way to communicate or give feedback to Shauna.

I understand that if I use location-based services on my mobile phone it may compromise my privacy. College Street Therapy Group has not been placed as a check-in location on various sites such as Foursquare, Gowalla, Loopt, etc. However, if I have GPS tracking enabled on my device, it is possible that others may surmise that I am a therapy client due to regular appointments.

I understand I have the following responsibilities with respect to therapy:

Process

I recognize that therapy is a mutual process in which there is a shared responsibility for decision making for goals and treatments. My responsibility includes the recognition of my own agency and capacity for choice and the necessity that I be engaged in the creation, development, and enactment of all therapeutic processes. If I have any questions or feel uncomfortable with the process of therapy, I understand that I have the right to bring these issues up in conversation. I may ask for a referral to another practitioner if I choose.

Fee

I agree be responsible for the fee of an individual therapy session. I understand further that I will be given reasonable notice before any anticipated change of fees. I understand that payment is to be made in the following way:

If I choose Interac e-transfers, I am expect to pay prior to the session
If I choose to pay by credit, cheque or cash, I am expected to pay at each session

I agree to pay for therapy services when delivered, unless other arrangements are agreed upon. I understand that the fee cannot be increased or reduced by me based on how I felt after an individual session.

At any time if I want to end therapy I may do so, but I may not withhold fees for sessions already given or any future sessions in which I continue to participate.

I understand that therapy sessions are 50 minutes.

Session Rescheduling and Cancellation

I understand that there is a 48-hour cancellation and rescheduling notice requirement. I agree to be responsible for payment for any scheduled session I do not attend if I have not given at least 48 hours notice. There is a fee for sessions missed or cancelled for any reason (including illness or emergencies) with less than 48 hours notice. This fee is to recover costs for that session time.

Medications and Medical Information

I will notify Shauna Cake of my prescription medications and any changes in their usage. I agree to share information regarding my mental and physical health as assessed by previous practitioners, including any disagreements I may have had with their perspective.

I understand that I have a right to access my file and copies of records upon my request, subject to reasonable notice.
I have a right to a receipt for therapy services upon my request, subject to reasonable notice.

Search Engines, Social Media and Technology

Have questions?

I’m happy to talk about any questions you may have. Informed consent is very important to me and I will work to address any concerns you have.