Parental/Legal Guardian Consent Form
Psychological Therapy
Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychological therapy, you have certain rights and responsibilities that are important for you to understand and I have corresponding responsibilities to you outlined below.
1. Psychological therapy has both benefits and risks. Risks may include experiencing uncomfortable feelings because the process of therapy often requires discussing the unpleasant aspects of your life. However, therapy has been shown to have benefits for many individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction with life, greater personal awareness and increased skills. But there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.
2. The first 1-3 sessions will involve a comprehensive assessment of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include and
whether we may need additional services to help support you with your consent. At that point, we will discuss your treatment goals and create an initial treatment plan so long as I am the best person
to help you, if I am not the best person to help you I will signpost you to the most suitable support to aid you with your recovery.
3. If you have questions, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second
opinion.
What information do you collect about me and how will it be used?
During assessment and therapy, personal and sensitive data will be collected. This will include personal details, family details, lifestyle, social circumstances, physical and mental health details, as well as basic background information such as contact details and name and address of your GP. This will be collected verbally, and a written record will be kept in notes taken during and/or after the session. This information will not be routinely shared, save for potentially in the circumstances described in the confidentiality section below.
The legal basis for collecting this information is that you consent to provide it, since collecting this information is necessary for the performance of the contract to which you are party. West Midlands Psychotherapy Services Ltd has implemented technical and organisational measures to ensure that personal and sensitive data remains secure. An audit of all the storage methods used by us has been completed in accordance with the EU General Data Protection Regulation and information is kept secure in line with industry standard best practice.
You have rights in relation to the data we hold about you. These are summarised below. If you wish to assert any of these rights, then you should contact your therapist.
The right to be informed about the collection and use of personal data
The right of access to your personal data
The right to rectification, to have inaccurate personal data held rectified
The right to erasure, the right to be forgotten*
The right to restrict processing, sharing of information. In certain circumstances we have a duty of care to share information with relevant agencies, please see the confidentiality section below
The right to data portability, the right for you to request data, to re-use it for your own purposes
The right to object to direct marketing and research
Rights in relation to automated decision making and profiling, details can be found on our website privacy policy
*Our service has an exception to erasure as Under Common Law West Midlands Psychotherapy Services Ltd will keep information about you for seven years after your last treatment date, and in the case of children, seven years after someone turns 18. After this date the data will be deleted.
What are the boundaries of confidentiality during therapy?
For therapy to be effective, confidentiality must be honoured. Information your child shares with me in his/her private sessions will be held confidential. However, the goals and progress of the therapy may be shared with you, any other legal custodial parent or guardian. Further information sharing beyond this will be contracted with your child. By law, confidentiality must be breached if a therapist suspects that any minor is being or has been abused, if a person plans to physically harm another person, or if a person plans to harm him/herself, in this case we would speak to the relevant services due to our duty of care to your child.
Further information regarding confidentiality:
Health care professionals do consult with one another from time to time. The most frequent example of this is with respect to the therapist’s supervision, where they will discuss case material with their supervisor in the interests of providing a better service to their clients. Where practical, such material is conveyed without identification. At other times, identification may be necessary, for example if another therapist is covering phone calls in the absence of your therapist.
Should we receive a Court order a therapist must testify or release any records that are kept about you/your child.
How do I make payment and what is the cancellation policy for appointments?
Making Payment
The session fee must be submitted prior to the session in order to confirm your session and for the session to take place, you will be sent a secure link in which to make payment, alternatively you may request our bank details to make a secure transfer.
Cancellation Policy
If you do not attend for a scheduled session, or you cancel giving less than 24 hours’ notice, the full fee for the session will be charged to cover our specialists fees. Unfortunately due to our company being a small business there cannot be an exception for the fee being charged as we have to cover our costs to continue providing a service. If you cancel giving more than 24 hours in advance, we can provide a refund of your fee. If you arrive late for your session, the full fee will still be charged, and due to the therapist’s other commitments the time cannot be extended.
How do I make a complaint if I a dissatisfied with the service?
We are sorry to hear you are not satisfied with the service, should this be the case please email us on info@thepsychotherapyclinic.co.uk we will respond within 10 working days. Please detail your name, your allocated therapist name, your preferred method of contact and contact details alongside details of your complaint. We will take your complaint seriously and it will be dealt with professionally.
Will I receive an emergency service?
Our therapists do not provide formal emergency services, however we have created a client care guide you can download below to help if you are in distress.
If you find you are experiencing high emotional distress ad you require further support the Samaritans provide a support service 24 hours a day for people who experience feelings of distress or despair, including those that could lead to suicide. They can be contacted by phone on 08457 90 90 90 or you can email jo@samaritans.org. Alternitively you can text SHOUT anonymously 24/7 on 85285. In addition please speak with your GP who can support you through this time. If you cannot keep youself safe and find yourself in an emergency situation you should seek urgent support by calling 111 or 999.
Print 