CONSENT FORM – 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 PSYCOLOGY

COUNSELLING SERVICES FOR MYSELF AND/OR MY CHILD

SERVICES OFFERED:

Individual, couple, or family counselling aimed at supporting the clientis) emotional, psychological and/or relational wellbeing. Services are voluntary and can be withdrawn from at any time without prejudice. Withdrawal from services will rescind this consent for that period of time.

PROGRESS / EFFECTIVENESS

To achieve the greatest progress in therapy, your therapist will work to provide the best and most appropriate therapy for you or your relationship. The primary modality used to do so is Emotionally Focused Therapy. You can facilitate this process by regular attendance, complying with recommendations and policies, self care following appointments and communicating openly and honestly. The length and frequency of sessions as well as the duration of the treatment varies, and can be discussed at the beginning and throughout the course of therapy. However, typically regular attendance is linked to client progress.

Because success or satisfaction with treatment cannot be guaranteed, you are requested to inform your therapist if you do not feel satisfied with the service. You and your therapist may then be able to work through the issues or modify treatment. In some instances, this may mean making an appropriate referral or terminating therapy. You may choose to leave therapy at any time, however, leaving therapру is best accomplished in consultation with your therapist.

SELF CARE

It is recommended that client’s schedule time for self-care the same day of the appointment, ideally following the appointment. This is helpful to help consolidate the changes made during the process of therapy.

SESSION LENGTH:

Sessions are typically 60, 75, or 90 minutes in length. This means 50, 65, or 80 minutes (respectively) of appointment-time dedicated to counselling, followed by 10 minutes of scheduling, payment collection and/or paperwork 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 occurs at the conclusion of each appointment. Payment can be made with a major credit card, check, e-transfer, or cash. E-transfer is to occur within the same day or prior to the appointment. At this time we cannot accept debit. A credit card is required on file even if you plan to use other payment methods (cash, e-transfer), Savanna Psychology, will charge your credit card for fee as arranged or in the absence of other payment in a timely manner with this form acting as your authorization to do so.

CENCELATIONS:

Cancelation of appointments made with over 48 hour notice will occur no charge. Cancelations of appointments made with less than 48 hours will occur a charge of %50 of the appointment fee. Payment of this fee is to be paid within a week of the missed appointment.

CONFIDENTIALITY:

All information will be kept confidential and secure by employees of Savanna Psychology following the College of Alberta Psychologists’ Standards of Practice. Limitations to confidentiality are below. In these cases Savanna Psychology staff would have to share information with the appropriate parties.

1) If it is believed that you are at imminent risk to your own safety or the safety of someone else

2) A protected person in your care such as a minor is being put at reasonable risk of harm

3) A legal subpoena is issued requiring the information.

By signing below I understand and acknowledge all above and consent to ongoing services for myself and/or my child. Unless otherwise stated this consent will expire 5 years from below stated date.

Name(Print)