Informed Consent – Client Service Agreement
This document contains important information about professional services and business policies or Norwest Wellbeing. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPM), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations.
The terms “we”, “us”, “our” “practitioner“, “facilitator” “hypnotherapist“, psychotherapist” “PSYCH-K Facilitator” and “Norwest Wellbeing” refer to the person providing the service to you. The term “you”, “client” or “patient” refers to any person or entity that visits our practice or contributes, is present or takes part in a session.
Although these documents are long and sometimes complicated, it is essential that you understand them. When you agree to this document, it will then form an agreement between You (the client) and Us (Norwest Wellbeing). We can discuss any questions you have at the time of consent or at any time in the future. The service provided is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client Norwest Wellbeing, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of.
1. Norwest Wellbeing, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
Goals/outcomes of treatment
There can be many goals for the client relationship. Some of these will be long term goals such as improving the quality of your life, learning to live with mindfulness and self-actualisation. Others may be more immediate goals such as decreasing anxiety and depression symptoms, developing healthy relationships, changing behaviour or decreasing/ending drug use. Whatever the goals for the service, they will be set by the clients according to what they want to work on in the session. Norwest Wellbeing may make suggestions on how to reach that goal, but you decide where you want to go.
Risks/benefits of services
Sessions are an intensely personal process which can bring unpleasant memories or emotions to the surface. There are no guarantees that the session will work for you. Clients can sometimes make improvements only to revert back after a time. Progress may happen slowly. All our services require a very active effort on your part. To be most successful, you will have to work on things we discuss outside of sessions. However, there are many benefits to the sessions.
Our services can help you develop coping skills, make behavioural changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger, learn to live in the present and many other advantages.
2. Appointments
Appointments will ordinarily be 50-60 minutes in duration; initial sessions may be up to 90 minutes, may be as often as once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide a minimum of 6 hours notice. If you miss a session without cancelling or cancel with less than 6 hours notice, you may be required to pay for the session [unless we both agree that you were unable to attend due to circumstances beyond your control].
It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the cancellation fee. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.
Confidentiality
Norwest Wellbeing will make every effort to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware. We may consult with a supervisor or other professionals in our practice to give you the best service. In the event that we consult with another practitioner, no identifying information such as your name would be released.
Norwest Wellbeing is required by law to release information when the client poses a risk to themselves or others and in cases of abuse to children or the elderly. If Norwest Wellbeing receives a court order or subpoena, we may be required to release some information. In such a case, we will consult with other professionals and limit the release to only what is necessary by law.
Confidentiality and Group Therapy
The nature of group therapy makes it difficult to maintain confidentiality. If you choose to participate in group therapy, be aware that your Norwest Wellbeing cannot guarantee that other group members will maintain your confidentiality. However, we will make every effort to maintain your confidentiality by reminding group members frequently of the importance of keeping what is said in group confidential. We also has the right to remove any group member from the group should she discover that a group member has violated the confidentiality rule.
Confidentiality and Technology
Some clients may choose to use technology in their sessions. This includes but is not limited to online sessions via Skype, telephone, email, text or chat. Due to the nature of online sessions, there is always the possibility that unauthorised persons may attempt to discover your personal information. Norwest Wellbeing will take every precaution to safeguard your information but cannot guarantee that unauthorised access to electronic communications could not occur. Please be advised to take precautions with regard to authorised and unauthorised access to any technology used in sessions.
Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your session.
3. Sessions
Record-Keeping
Norwest Wellbeing may keep records of your sessions and a treatment plan which includes goals for your session. These records are kept to ensure a direction to your sessions and continuity in service. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Should the client wish to have their records released, they are required to sign a release of information which specifies what information is to be released and to whom.
Records will be kept for at least 7 years but may be kept for longer. Records will be kept either electronically on a USB flash drive or in a paper file and stored in a locked cabinet in the Norwest Wellbeing’s office or electronically on it’s online servers or client portals.
Professional Fees
You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by credit card or cash. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires our participation, you will be expected to pay for the professional time required. Fees are non-negotiable. To receive sliding scale fees, you must present proof of income through recent pay stubs or tax forms. Fees are subject to change at Norwest Wellbeings’ discretion.
Fee Schedule
$250 initial session fee
$200 per hour charge for each subsequent one-hour session
We may, at times, offer discounted sessions or packages.
Our full fee structure can be found on our website on the appointments page
Insurance
If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, we can assist you to the extent possible in providing our provider number for claims and ascertaining information about your coverage. Still, you are responsible for knowing your coverage and for letting Norwest Wellbeing know if/when your coverage changes.
You should also be aware that most insurance companies require you to authorise Norwest Wellbeing to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information which will become part of the insurance company files. By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance.
We reserve the right to change this consent from time to time.
