Consent and Disclosure Form
The General Data Protection Regulation (GDPR) requires that psychological and medical data is treated with strict confidentiality. Joseph adheres strictly to the ethical and confidential guidelines of professional practice.
Consent to treatment
I confirm that I have been given information about the proposed psychological treatment and hereby consent to the treatment.
Form should be signed by parent or guardian if client is under 18 years of age
Disclosure of Information
In line with consent and disclosure guidelines for medical related data and the ethical codes of conduct of healthcare professionals, strict confidentiality is required for all confidential, medical information.
The Psychotherapy clinic will only share the your confidential information with the professional parties that you have provided your previous consent.
Sometimes it may be necessary to share confidential information with another health care provider, for example your GP/doctor, in order to provide you with the best possible care/service. In cases where there is a safeguarding concern/concern about risk to yourself or others, we may share this information with your GP/statutory services.
By signing below and giving consent to keep your contact details on our appointment system and to email you – text you with psychoeducational materials and reminders about your therapy appointments. Your contact details will be kept electronically with a password and will be deleted after a month of finishing therapy. Furthermore, you are authorising Joseph Poullis to be involved in your therapy and share confidential information as outlined above.
I have read and understand this information. I understand I can revoke my consent at any time during my rehabilitation by writing to Venkat, Dale View, Park Road, High Barnet EN5 5SF.
Name (block letters)
The following is the contract between you and your therapist. It is presumed that you have accepted these terms and conditions if you proceed with therapy.
Payment: Payment is taken in full by your therapist at the end of each session by cash or cheque. We regret that we cannot accept credit or debit cards at our practice location.
Regularity of sessions: Once you have agreed to therapy, a weekly time slot (of 50 minutes) will be reserved for you. We regret that any missed sessions or cancellations without 48 hours notice will be charged at the full fee. This is so that the therapist can set aside the same time for you each week.
Therapist absences: The therapist will give you as much notice as possible of holidays and other absences and you will not be charged for your therapist’s absences.
Arrival and late attendance: We regret that we cannot make up time if you are late. There is a waiting room if you wish to arrive earlier than your appointment time. Please do not arrive intoxicated (no alcohol or drugs, other than prescribed drugs).
Client commitment: Therapy is not a magic ‘cure’ and you will be expected to share responsibility for your progress.
Ending Therapy: There may be times when therapy seems difficult and you wish to discontinue. Often, it can be beneficial to work through these challenges. However, if either you or the therapist thinks it is time to end the therapy then a mutual discussion should take place including how best to end the therapeutic relationship.
Non-attendance of Sessions: If you do not attend two consecutive sessions and do not contact your therapist beforehand to inform them that you are unable to attend, your sessions will be terminated.
Confidentiality: Sessions are confidential although we are under legal obligation to inform the relevant parties if you are a danger to yourself or to others. Your therapist will be in supervision as part of their commitment to good practice but the duty of confidentiality is extended to the supervisor/s. If you see your therapist outside the office premises, the therapist will not approach you unless you wish to do so – this is to respect your confidentiality.
Extra work undertaken: If you wish us to write any reports or letters on your behalf, the therapist’s time in preparing such reports will be billed to you at the hourly rate.
Complaints: If you are unsatisfied for any reason, please send details of your complaint to the director firstname.lastname@example.org) and we will endeavor to address your concern. Any official complaints will be directed to your therapist’s professional organization – the BPS.
Emergency: We do not offer emergency support as we cannot guarantee our availability to you. If you are in danger in any way please contact emergency services, your GP or the Samaritans (08457 90 90 90).
By making an appointment online via the calendar of our website you are authorising the above terms and conditions and approval of a consent as per content.
I have read and accept the above terms and conditions
If you feel so troubled that you consider harming or killing yourself, or you feel at the end of your tether, please get in touch with one of the helpful organisations below that can be contacted after hours and during the day.
Heads Together: Text www.headstogether.org.uk (mental well-being) CALM: Online, Phone www.thecalmzone.net, 0800 585 858 (Campaign Against Living Miserably) Papyrus: Online, Phone www.papyrus-uk.org, 116 068 4141 (Suicide Prevention Charity) Mind: Online, Phone www.mind.org.uk, 0300 123 3393 (mental health charity) Childline
0800 1111 (counselling service for children and young people) Samaritans.org
116 123 (provides emotional support to anyone in emotional distress, struggling to cope, or at risk of suicide)
Advice when attending a face to face appointments
To make sure that whilst attending your session we are following the government’s guidance to ‘stay alert, control the virus, save lives’ the following information will help to keep you safe when you are attending for face to face treatment.
If you have a cough, feel feverish/have a high temperature or experience a loss or change to your sense of taste/smell then please self-isolate for 7 days and do not attend your appointment. Please contact me to advise that you will not be attending and the reason so I can let your referrer know.
Please be assured that if I display any of the above symptoms, following the advice to self-isolate for 7 days to keep you and others safe, I will either cancel the appointment or, where possible, reschedule our appointment to remote therapy to keep the momentum of our therapy going.
In session we will follow Public Health England advice and safety procedures:
• Arrive on time for your appointment to minimise contact with others
• Wash your hands with soap and water or use hand sanitiser gel before and after your appointment
• Bring your own tissues with you and use them to catch any coughs or sneezes and use a hand sanitiser gel afterwards. A bin will be provided for disposal of tissues.
• Avoid touching your eyes, nose and mouth where possible
• Bring your own water bottle to use through the session and take this way with you
• Seating will be arranged at a 2-metre distance and you can ask me to wear a mask and wear one yourself if you prefer
• Paper will not be exchanged but notes can be taken in session for you to reflect on for between session work – if for any reason you are unable to take notes, I will take them and e-mail to you afterwards
• All surfaces and points of contact will be cleaned between appointments with disinfectant
• Please be aware the environment may feel less comfortable due to disinfecting and removal of non-essential soft furnishings etc
Please note that I will be following the same advice to keep you safe in our face to face appointments.
If within 14 days of your appointment you begin to display symptoms of Covid19, test positive or are contacted by the NHS track and trace service you should inform me as soon as is possible.
If I display symptoms, I will contact you myself and provide your details to NHS track and trace.