Consent.
Please read this information carefully because it contains important information about the center’s policies and therapeutic practices. If you have questions, please write them down and ask at your first meeting. When you sign this form, it represents an agreement between us. You will be given a copy of this form if you wish. Please initial each page after you have read the contents.
Types of Services Provided: At your initial visit/intake session, you/your child will be interviewed about life history, current situation, what brings you in for services, and the goals you have for therapy/assessment. You may also be asked to fill out some questionnaires to assist in understanding how to best help you. Diagnostic Intake visits typically last 60-75 minutes, sometimes less.
We may decide the best way to help you is through psychological /speech/ and language/ occupational/ ABA assessment/testing and/or psychological/ speech and language/occupational/ ABA treatment. Psychological/Developmental/Behavioural testing involves exploration of diagnostic possibilities. Particular diagnostic outcomes cannot be guaranteed and do not always match the initial concerns discussed so please remain open to various possibilities. Appointments can last anywhere from one to several hours depending on the age of the patient, presenting concerns, attention, and behavior during testing. The Therapist will attempt to complete all testing in one session, whenever possible. Rating forms are also given to parents and teachers when needed. A feedback session, typically lasting 50-60 minutes, will be scheduled to review results and recommendations of testing in detail. A Psychological/Developmental/Behavioural Assessment Results report will be provided to you at the conclusion of testing.
Treatment/Intervention sessions typically last 45-50 minutes, and parental involvement for children/adolescents will be required. Treatment will often involve work/tasks/activities for you/your child to complete prior to the next session. The number of treatment sessions needed is different for everyone and difficult to estimate. Throughout treatment we will assess progress towards your goals and revise goals as needed. If you are dissatisfied with testing or treatment at any time, please discuss this with the therapist so that we can try to address your concerns. We will make a referral to another therapist if necessary and/or at your request, but we are not responsible for care received from professionals to whom we refer you. It is your right to discontinue treatment at any time. Sometimes, when beginning or throughout treatment, people experience a temporary increase in their distress because the process of addressing and clarifying personal issues can be difficult or painful. On the other hand, treatment has been shown to be beneficial for those who participate, although there can be no guarantee as to your response to treatment.
• Feedback sessions for Psychological Testing are billed as Therapy/Intervention and often require 60+ minutes.
• Therapy/Intervention sessions typically require 30+ minutes.
If you become involved in legal proceedings that require the therapist’s participation, you will be expected to pay for the professional time even if the therapist is called to testify by another party. Because of the difficulty of legal involvement, there will be charges for activities such as testifying in court or depositions as well as court-related preparation and travel time. The timing of court proceedings is unpredictable so you will likely have to pay for a full day of time. Payment will be due prior to the date of my participation.
Contacting the Therapist & Emergencies: The Therapist is usually not immediately available. Although could be typically in the office Monday through Friday (except for holidays. Please call The Bridge Reception at (04) 3116259 or email admin@thebridgelearning.com; please initial to indicate your understanding that The Bridge/Therapist cannot guarantee the security of email communication ___), and the therapist handling the client will return your communication within 2-3 business days. Email should never be used for emergency situations. There will be little to no discussion of treatment-related matters via phone/email; please schedule an appointment to discuss such matters. If you experience an emergency and cannot reach the therapist, please call your family doctor or contact the nearest available emergency services. If the Therapist/therapist will be unavailable for an extended period of time, we will discuss what coverage options you would like, and I will give you the name of another therapist to contact if you wish. With regard to social media, the therapist/clinician do not accept “friend” or contact requests from current or former patients on social networking sites (Facebook, LinkedIn, etc.).
Confidentiality and Disclosure: Your patient information is always held confidential in accordance with both legal and ethical standards. This information includes patient appointments, session notes, test results, written reports, demographic information, and financial information. I may ask you to sign release of information forms for me to communicate with other professionals to coordinate you/your child’s care; you have the right to refuse to sign these forms if you so choose. Additionally, I may seek consultation from colleagues regarding your care, but no identifying information will be shared. If I see you in public, I will not acknowledge your presence so as to not break your confidentiality, but I will respond if you greet me first. Please be aware that there are certain circumstances in which I am required by law to breach patient confidentiality. These circumstances include:
• If I believe that a patient is a danger to him/herself or others
• If I believe that an individual is the victim of child/elder/disabled adult abuse or neglect (I am a mandated reporter)
• Court mandated subpoenas
When working with a minor, the confidentiality of the minor is important in order to have an effective therapeutic relationship. The therapist will speak with parents to try and ensure that minors experience the same degree of confidentiality as adults. However, parents do have the legal right to examine a minor’s treatment records. Please note that any parent/legal guardian has rights to the information specifically pertaining to a child held within a child’s treatment records unless there is a court document stating otherwise.
Professional Records: The laws and standards of therapy and treatment require that the center maintains treatment records. Information discussed during sessions/visits, on the phone, and via email all become part of your professional record. You are entitled to receive a copy of you/your child’s records, or a report/summary can be prepared for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to read. If you wish to see your/your child’s records, it is recommended that you review them with me so that we can discuss the contents.
Release of Liability: You release the Therapist of liability for your therapy in the following situations: if you/your child fails to show for an appointment and the Therapist does not hear from you within one week of that missed appointment, and if you cancel an appointment without rescheduling, you are welcome to reschedule at any time, provided that any past balances (including missed appointment fees) are paid. Failing to show and/or failing to provide 48 hours’ cancellation notice 2 times in a row or 3 times within a 3-month period may result in termination of psychological services with the Therapist and resultant release of liability. Any other justifiable reason for the termination of your therapeutic services with the Therapist will also result in a release of the therapist from liability for your therapy/treatment care. If there are extenuating circumstances, such as family emergencies or sudden business trips, please contact The Bridge as soon as possible to inform the Therapist.