Consent and Policy

Information and Informed Consent for Therapy

(Restore Support Services)

General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

I understand and agree for a Counsellor, Therapist, Social Worker and/or other professional from Restore Support Services to work with me and/or my whānau. If special conditions or concerns apply these will be discussed and agreed upon prior to beginning.

Refunds and Payments and Cancelation Policy

I agree to notify Amy Colonna 48 hours before or as soon as possible via text/email, if I am/we are unable to attend any booked session or need to reschedule.

Clients under a service- If cancelation is under 48 hours notice, I may still submit that session as being used as I am unable to offer that time slot to another client, In certain circumstances, with agreement, I may choose not to claim that session and reschedule.

Private Clients- Any private session booked, payment before first session is required to secure space, in cases where the session is no longer required, payment is 50% refundable. For ongoing private sessions, payment is due within 7 days of the scheduled session, future appointments will only be booked if previous session is paid in full, unless previous agreement was made. Where possible we may be able to reschedule the session, if prepaid this can possibly be used as credit for a rescheduled session, this allowance will only be given once every six months and 48 hour rule applies.

If you choose to change providers or discontinue your sessions, please just inform if this feels safe to do, no explanation required in most cases, and follow 48-hour policy if possible if sessions have been booked ahead.

Confidentiality

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons, within 20 business days.

Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and # 4.
6. If a court of law issues a legitimate subpoena for information stated and in accordance with the court order, this will be disclosed and discussed with client.
7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

There are limits to client confidentiality that are important for you to understand. In circumstances when we are concerned about your safety or the safety of someone else, we are legally required to break confidentiality to inform the relevant agencies to ensure safety. If this arises I will endeavour to speak with you first, however this may not always be possible. Social Workers and Counsellors are also required to undertake regular supervision for the entirety of our career. There may be times when I discuss my work with you in supervision in order to provide the best care for you. My supervisors are also bound by confidentiality.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside

Contact/Crisis/Complaints

Due to the limitations of working in private practice, I am not able to offer a mental health crisis or emergency service. The mental health crisis number 24/7 in the Hauora a Toi Bay of Plenty region is 0800 800 508 and the emergency services number is 111 for imminent risk of harm, or call/text 1737 for support or call 24/7 free suicide prevention Lifeline 0508 TAUTOKO (0508 828 865)

In cases where you feel you would like to submit a complaint or request any further support or place feedback regarding your service, please either contact the service your referral was originally made from or request complaints form from Restore Support Services directly, by emailing restoretauranga@outlook.co.nz

Alternative Support/Closure

Sometimes it may become clear that a different service might be more able to meet your needs. If this happens, I will support the referral to an agreed service and/or signpost you to that service. I will ensure I explain my reasons for referring you to another service so that you can make an informed choice about your options.

I understand that if I/we do not make contact for 28 days, my/our file may be closed. If I/we wish to re-engage, another referral form will need to be completed and I/we may be put on a waitlist. Some services allow files to stay open for up to six months, others have set timeframes, feel free to check in on this if required.

Consent and Confidentiality Statement

I have the legal status to consent for the person listed below to receive a service. I agree to pay all invoices for psychological support from Amy Colonna. I understand that this is a therapeutic process and that the therapist will discuss any concerns they have with me directly if possible and be open and honest with me about any discussions with, or possible referrals to, other organisations.

I understand that any information disclosed to the therapist (and possibly their supervisor) is confidential, except in cases where there is a concern regarding the client or another person’s welfare. Safety is the priority and the therapist may need to consult with others if a safety or treatment concern arises. Any information held about me by the therapist will be done so in accordance with the rules of the Health Information Privacy Code 1994 and the Privacy Act 1993.

Declaration: By signing (in first session), you are indicating that you have read, understood and agree to terms of the service agreement and contents.