CONSENT FORM – Savanna Psychology

Savanna Psychology
Email:therapy@savannapsychology.com
Phone:403-910-7677 
www.savannapsychology.com
Suite 480, 301-14 Street NW Calgary AB.T2N 
2AI

Informed Consent – Savanna Psychology

Counselling Services for Myself and/or My Child

Services Offered

Individual, couple, or family counselling aimed at supporting the client’s emotional, psychological, and/or relational well-being. Services are voluntary and may be withdrawn at any time without prejudice. Withdrawal from services will revoke this consent for the applicable period.

Progress / Effectiveness

To achieve the greatest progress in therapy, your therapist will work to provide the most appropriate therapeutic approach for you or your relationship. The primary modality used is Emotionally Focused Therapy (EFT). You can support this process through regular attendance, following recommendations and policies, engaging in self-care between sessions, and communicating openly and honestly.

The length and frequency of sessions, as well as the overall duration of treatment, may vary and can be discussed at the beginning of therapy and throughout the course of treatment. However, regular attendance is typically associated with greater therapeutic progress.

As success or satisfaction with treatment cannot be guaranteed, you are encouraged to inform your therapist if you feel dissatisfied with the services provided. You and your therapist may then work collaboratively to address concerns or modify the treatment approach. In some instances, this may involve making an appropriate referral or terminating therapy. You may choose to discontinue therapy at any time; however, doing so is best accomplished in consultation with your therapist.

Self Care

Clients are encouraged to schedule time for self-care on the same day as their appointment, ideally following the session. This helps consolidate the changes made during the therapeutic process.

Session Length

Sessions are typically 60, 75, or 90 minutes in length. Of this time, 50, 65, or 80 minutes respectively are dedicated to counselling, followed by approximately 10 minutes for scheduling, payment collection, and/or administrative paperwork completed by the therapist.

Session Fees

Individual counselling fees: 60 minute session: $200.00/75 minute session: $250.00/90 minute session: $300.00 Fees increase yearly following the Psychology Association of Alberta’s recommendations.

Payment

Payment for sessions is due at the conclusion of each appointment. Payment may be made by major credit card, cheque, e-transfer, or cash. E-transfers must be completed on the same day as, or prior to, the appointment. Debit payments are not accepted at this time. A valid credit card is required to be kept on file, even if you intend to use an alternative payment method (e.g., cash or e-transfer). In the absence of timely payment, Savanna Psychology is authorized to charge the credit card on file for the agreed-upon fees. This form serves as your authorization for such charges.

Cancellations

Cancellations made with more than 48 hours’ notice will not incur a charge. Cancellations made with less than 48 hours’ notice will incur a fee equal to 50% of the scheduled appointment cost. Payment of this fee is due within one week of the missed appointment.

Confidentiality

All information will be kept confidential and secure by employees of Savanna Psychology in accordance with the College of Alberta Psychologists’ Standards of Practice. The limits to confidentiality are outlined below. In these circumstances, Savanna Psychology staff may be required to share information with the appropriate parties:

If it is believed that you are at imminent risk to your own safety or the safety of another person.
If a protected person in your care, such as a minor, is believed to be at reasonable risk of harm.
If a legal subpoena or court order is issued requiring the disclosure of information.

By signing below, I understand and acknowledge the information outlined above and consent to ongoing services for myself and/or my child. Unless otherwise stated, this consent will expire five (5) years from the date stated below.