Informed Consent
Below, you can read the Informed Consent Form. Yes, it is quite long, but the goal is to cover all the important aspects of being in therapy so both client and counsellor are on the same page about things like costs, cancelation, conflict, communication, and more...
Informed Consent Form
Introduction
I, _________________________, hereby acknowledge that I have voluntarily chosen to participate in counseling services provided by Adam Janusz (“the counsellor”), for the purpose of addressing my mental health concerns.
I am aware that the counsellor has completed all Master’s degree requirements in Counselling Psychology, including university credits, clinical practicum requirements and continuing education courses to qualify as a registered clinical counsellor in British Columbia.
Nature and Purpose of Counseling
Counselling is a collaborative process through a therapeutic relationship between me and the counsellor. The purpose of counselling is to explore and advance my mental health goals, including:
- promoting self-awareness and self-compassion
- strengthening self-regulation and coping skills
- improving relationships and interpersonal effectiveness
- integrating past events and experiences to remove barriers to wellbeing
- encouraging new behaviours to build self-efficacy
The counsellor will guide and assist in relation to the above goals, promoting a safe, collaborative, and professional environment. The counsellor will strive to stay aligned with my goals and intentions and will seek my feedback to maintain alignment with my goals, making necessary adjustments, as needed. I agree to inform the counsellor if anything arises that impedes or distracts from my goals and wishes for therapy.
Confidentiality
I understand that all information disclosed during counseling sessions is confidential, except in the following circumstances:
If I pose a threat to myself
If there is a risk of imminent harm to others
If there is suspected abuse or neglect of a child, elder, or vulnerable adult
If a court order requires the release of information.
I understand the counsellor will consult with other professionals for the purpose of supervision and professional development, while maintaining the confidentiality of my name and identifying details. Any supervisor or consultant will share the same ethical duty to protect any confidential information.
Risks and Benefits
I acknowledge that counselling may involve discussing difficult topics. At times, I may experience emotional discomfort. In addition to the risks, I acknowledge the potential benefits of therapy, including: improved emotional well-being, enhanced coping skills, and better interpersonal relationships. I agree to inform the counsellor if anything arises that is too overwhelming, too distracting or otherwise not advancing my goals.
Duration and Frequency of Sessions
Sessions are generally between 50-60 minutes long, at a frequency of once per week. The counsellor and I will collaboratively determine the exact frequency and duration of counseling sessions. The counsellor may occasionally go over the 50-60 minute mark, if they feel it is useful or necessary, for example, in cases of high distress toward the end of session. I will not be billed for this additional time nor expected to compensate for it in any way.
Fees and Payment
I agree to the fee for each counselling session being $_________. No GST or other taxes/fees will be added. The preferred payment method is e-transfer. A receipt will be provided promptly upon request.
The fee will be held at the price above for at least 10 sessions. After 10 sessions, the price may be re-evaluated. If a fee increase is imminent, the counsellor will provide notice a minimum of 3 sessions before the increase is to take place. The counsellor will provide referral options and resources if I am unable to continue at the new fee. I am welcome to request the following accommodations:
· a temporary reprieve from fee increases
· a phased increase to the new fee over several sessions
· a reduction in the frequency of sessions to reduce cost
Payment is due after each session unless other arrangements have been made. I agree to pay within 7 days. I understand that failure to pay for a session or a cancellation fee may result in the suspension of future appointments until the outstanding fees are settled.
Cancellation and Rescheduling
The counsellor understands that unforeseen circumstances may arise, requiring me to cancel or reschedule my appointment. I agree to provide a minimum of 24 hours’ notice for any cancellation or rescheduling.
Late Cancellation or No-Show
If I must cancel or reschedule my appointment within 24 hours of the scheduled time or fail to attend the appointment (no-show), a cancellation fee of half the session fee will be charged. The cancellation fee is due at the time of the missed appointment and must be paid before scheduling any future appointments.
Illness
In the event I am sick with flu-like symptoms on the day of a scheduled in-person session, I will notify the counsellor by email as soon as possible and arrange to postpone the session or switch to a virtual session.
Emergency Situations & Exceptions
In the event of an emergency, or sudden onset of illness, the cancellation fee may be waived. I will contact the counsellor as soon as possible to discuss my situation.
Counsellor Cancellation
In rare circumstances, the counsellor may need to cancel or reschedule an appointment. Every effort will be made to provide at least 24 hours’ notice, and a new appointment will be scheduled promptly to make up for the lost session. If the session in cancelled less than 24 hours in advance, the counsellor will waive my next cancellation fee.
Location of Sessions & Privacy
Sessions will take place in person or virtually. In either setting, the counsellor will provide a private location, free from distraction and away from others. In virtual sessions, I commit to being in a private location similarly free from distraction and away from others. I will notify the counsellor if I cannot meet from a private location. It may be possible to put in place accommodations, such as wearing headphones. The counsellor may end or cancel a session if my location is noisy, distracting or if others are present in the room.
Physical Touch
Physical touch during counselling may or may not be helpful, depending on the person and the situation. The counsellor will generally not touch me in session. However, in certain contexts, such as a moment of extreme grief, a hand on the shoulder or a hug may be offered. The counsellor will always ask permission before doing so. I have the right to accept or decline an offer of physical touch for any reason, with no explanation required. The counsellor will not be offended if I decline an offer, understanding that attitudes to touch are highly variable and not a personal comment on the counsellor.
Touch Preference Scale:
No touch please ----------- moderate touch ok, in context ----------- Touch is welcome
0 1 2 3 4 5
My preference (in-person only): ____
Homework
The counsellor may provide psychoeducation (or “homework”) in the form or articles, videos, worksheets, as well as exercises to do between sessions. I understand the resources offered are optional and supplementary, and I can accept or decline to engage with them, on a case-by-case basis. The counsellor will support any level of engagement with homework.
Homework Preference Scale:
No homework, please -------- neutral / unsure / depends ------------- Yes, please!
0 1 2 3 4 5
My Homework preference: ____
If I agree to do an activity, worksheet, etc. the counsellor may wish to discuss the following:
· my thoughts or feelings about the homework
· my reasons for doing or not doing it
· my resistance around doing it
· my feedback on the quality or value of the exercise
The counsellor is motivated to understand me better based on my response to the homework. Not completing the homework is also considered a valid response and the counsellor will not judge me for not completing the task.
Transference & Dual Relationships
The counsellor/client relationship is uniquely one-sided, where the counsellor is paid to learn about the client on a deep, intimate level, but the client knows relatively little about the counsellor. I understand that this one-sidedness may lead to a variety of feelings toward the counsellor. This is called transference and may include various assumptions or beliefs about the counsellor and can include romantic and/or sexual feelings. I am invited to share any feelings or thoughts I develop about the counsellor in session. The counsellor understands that transference is a normal part of counselling and believes positive learning can occur through exploration to advance my mental health goals. I acknowledge that conversations related to transference are welcome at any time.
I acknowledge that the one-sided dynamic described above places me in a uniquely vulnerable position. Because of this, any relationship outside the therapeutic relationship is not permitted, for at least a period of 2 years after sessions cease. This includes meeting outside of therapy sessions, interactions via email, text or phone not related to therapy, or romantic or sexual activity of any kind. I accept these restrictions and acknowledge they help to protect my emotional safety, as well as the counsellor’s ethical duty of care.
I agree to not probe about the counsellor’s personal life, including their personal relationships, past experiences or political beliefs. I accept that the counsellor may redirect personal questions back to me and my goals, on a case-by-case basis.
The counsellor may occasionally self-disclose if it is useful to my issues, such as validating shared experiences or offering examples of relevant situations. I am permitted to discuss these self-disclosures when they arise.
If I see the counsellor in public settings outside of therapy, by default, the counsellor will not acknowledge me to respect my privacy. I can waive this desire for privacy by saying hello, thus signaling to the counsellor that it is okay to respond in kind, ex. saying hello or waving back. If I see the counsellor engaged in private social activities with others I will not interrupt or disturb them, in order to respect their privacy.
Communication Between Sessions
Between sessions, I will not seek counselling via email, text or phone. Communication between sessions via email will be limited to discussing scheduling, exchanging resources such as links, worksheets, assessments or documentation, and about referrals or external communication with professionals, clients, employers/schools. Texting between sessions is not permitted. If I am in crisis, I will seek support from local crisis lines or emergency medical services. If I seek emergency medical care for my mental health, I will notify my counsellor as soon as it is practical to do so.
Gifts, Goods & Services
The exchange of goods and/or services outside of the counselling contract is generally not permitted. I will not offer, and the counsellor will not accept, services or goods. For example, if the client is a bookkeeper, offering to do the counsellor’s taxes is not permitted. Similarly, giving gifts to the counsellor is not advised, and I acknowledge the counsellor may decline a gift for ethical reasons. However, a small gift, such as a box of chocolates, is acceptable, up to a value of $50. The counsellor has no expectation of receiving small gifts.
Conflict
In the counsellor-client relationship, there may inevitably be disagreements, disappointments, or other ruptures in the therapeutic alliance. I acknowledge that this may happen. I am open to addressing ruptures in session, with the understanding that working on the counsellor-client relationship is therapy—it supports the therapeutic alliance and practices interpersonal skills. This may include the counsellor apologizing, seeking out and responding to negative feedback, and pledging to improve. Likewise, the counsellor may bring up my behaviour, share impact and concerns, request changes and set boundaries or consequences for continued behaviour. In these situations, both sides are encouraged to use the following steps:
1. Describe the incident or behaviour factually
2. Share thoughts, feelings and impact of the behaviour
3. Negotiate a resolution or different behaviour
4. Set boundaries or future consequences if behaviour continues
Termination
I have the right to terminate counselling at any time. I do not need to explain my reasons for termination to the counsellor. I am free to provide notice either in person, or via email or simply to not schedule a subsequent session.
In certain situations, the counsellor may terminate counselling. This is done to ensure the best level of care. Examples include:
· if there are indications that psychiatric treatment and/or medication is required, ex. schizophrenia or bipolar disorder
· if certain mental disorders are evident, ex. antisocial personality disorder, pedophilic disorder
Termination may also be required if the counsellor cannot provide adequate support for the following reasons:
· there is a conflict of interest, ex. the client’s partner is already a client with the counsellor, or if the client is an employee, employer or colleague of the counsellor in another setting
· the counsellor develops romantic/sexual feelings for the client
· the client’s mental health concern has significant similarities to the counsellor’s active mental health concerns, ex. the client is grieving a death in the family while the counsellor is grieving a similar loss
If the counsellor terminates therapy, they will provide a referral to another practitioner or other resources and work with me to transition as smoothly as possible. Due to privacy concerns, I understand the counsellor may not always be able to fully disclose the reasons for termination.
Record Keeping
The counsellor will keep records of our sessions, which will be stored securely and will remain confidential. I have the right to access my records upon request, subject to legal and ethical limitations.
Contact Information
It is my responsibility to provide accurate and up-to-date contact information. I will notify the counsellor of any changes to my address, email, phone number or emergency contacts.
Client Rights
I have the right to be informed about the therapeutic process, including the goals, methods, theories and evidence base of counselling techniques. I am encouraged to ask questions and provide feedback throughout the counselling process.
Agreement
I have read and understand the information provided in this form. I voluntarily consent to participate in counseling with Adam Janusz.
Client's Name: ____________________________
Client's Signature: ____________________________ Date: ___________________
Counsellor's Signature: ________________________ Date: ___________________