Fees Counselling Disclaimer Booking form
COUNSELLING AGREEMENT
For those wishing to use our face-to-face or telephone counselling service.
1. Client Record Details -- I confirm that all information provided by me (the client) regarding my name, gender, age and place of residence is true and correct. If I choose to conceal my true identity from my counsellor, I will tell the counsellor, who may or may not choose to proceed on this basis. (Cash or money-order payments in advance will be required of clients not using their real name etc.)
2. Confidentiality -- I understand that Clearsight Counselling will protect my private and confidential information by all reasonable means. Furthermore, that Clearsight Counselling will store and maintain my electronic and hardcopy information in accordance with the Privacy Act. I understand and accept that if, in the mind of the counsellor, there seems to be a real likelihood of harm being done to a client, or harm to others being done by a client, Clearsight Counselling reserves the right to make a report to an appropriate authority.
3. Emergency Situations -- I agree that, if at any time, I feel, think or believe I am in a crisis a situation and require emergency assistance, I will not rely solely on Clearsight Counselling and will seek appropriate assistance elsewhere. (For example, by phoning: Emergency - '000'; Lifeline 24 hour crisis counselling line - 13 11 14; Problem Gambling Help Line - 1800 622 112 or a local doctor/hospital).
4. Referrals -- I accept that Clearsight Counselling counsellors have a duty of care to all clients and that I may be referred to a service other than Clearsight Counselling if the counsellor(s) decide that they are unable to assist me.
5. Clinical Supervision -- I accept that counsellors associated with Clearsight Counselling will undertake confidential, professional clinical supervision (as is best practice when counselling) and that within this context my case may be discussed.
6. Research and Education -- I accept that non-identifiable information about me/my case may be used for the purposes of research and/or education.
7. Copyright -- I understand and agree that I will comply with Copyright Laws and will not distribute Clearsight Counselling's printed, e-mail or other communications in a way that is inappropriate, disrespectful or harmful to myself, or others (including Clearsight Counselling).
8. Legal Jurisdiction -- I understand and accept that the Clearsight Counselling service is governed and bound by the laws of the State of Western Australia.
9. Fees -- I understand and accept that Clearsight Counselling fees are to be paid prior to or at each counselling session. I agree to state the amount of time I require for counselling before the session commences and that the session will conclude at the end of the agreed time. I agree to pay the amount stipulated on the fee schedule for each session. I agree to pay a cancellation/rescheduling fee if I cancel or reschedule an appointment without giving at least 36 hours notice to my counsellor (except in the case of a medical emergency). I accept that fees are not refundable (except under extraordinary circumstances).
10. Termination of Services -- I agree to inform my counsellor if I wish to terminate counselling. I also understand and accept that the counsellor may withdraw services at any time and that in this case a reason(s) will be provided to me.
And additionally, for those wishing to use our online (e-mail) counselling service,
11. I (the person applying for Clearsight's online counselling services) acknowledge and assert that I ...
a) Can use PC-based electronic communication systems with at least a reasonable degree or proficiency.
b) Can speak, write, read and understand English and English concepts with at least a reasonable degree or proficiency.
c) Do not have a diagnosed mental illness that could interfere with my ability to communicate online.
d) Am not feeling suicidal; nor contemplating harming myself in any way, nor am I relying solely on Clearsight Counselling for assistance with my personal concerns.
e) That I am eighteen (18) years of age or over.
12. Security of E-mail Communication -- I understand and accept that Clearsight Counselling is not responsible in any way for the security of my own electronic (or printed hardcopies) of e-counselling communications that I may have received and retained and that, Clearsight Counselling is not responsible if someone finds, reads and/or seizes these communications; and, that e-mails from Clearsight Counselling are not encrypted and therefore may be subject to access by others online.
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