Therapy Consent Form

Consent to Counselling and Psychotherapy Services

This consent to counselling and psychotherapy services documents that I, give permission and consent to Rocky Health to provide counselling and/or psychotherapy services to me/us and/or my child/ren, in accordance with his/her professional assessment and aligned with the following legislation, policies, and expectations.

Situations in which my therapist or Rocky Health may be legally obligated to release my information without consent include:

Personal Health Information Protection Act and Circle of Care I understand that my information may be shared on an as-needed basis with other health care providers working directly with me if that information is needed to provide me care. I understand I have the right to decline having information shared with other members of my care team, and I understand that this can impair the coordination of my care in some cases. If I have members of my care team outside of Rocky Health with whom I would like information shared, I may request that my therapist share information and understand that I may be required to sign a consent form to release this information.

I understand that psychotherapy best practice involves regular case consultation among therapists, and consent to my therapist seeking consultation from the Rocky Health therapist team. I understand that all consultation meetings are held via secure and confidential video conferencing that meets the requirements of the Personal Health Information Protection Act.

Documentation of Personal Information

I understand that my therapist is required by their professional regulatory body to document relevant data related to our sessions. My therapist will write a short note following the session documenting the theme of the session, their observations, any actions taken, and progress made.

I understand that the staff of Rocky Health may need to access some personal information in order to administer the program. This does not include clinical records but may include demographic data. This will not be shared outside of Rocky Health unless legally required as outlined above.

I have a right to review my clinical record and can request to view it for a small printing fee. My record will be kept on a secure electronic health record in compliance with all relevant privacy legislation. My record will be kept for ten years following my completion of services, at which point it may be destroyed in accordance with PHIPA standards.

Virtual Therapy

Accessing virtual services allows me a greater choice of therapists with skills matching my needs, and limits travel time. Virtual therapy is convenient and effective, and most therapy provided by Rocky Health is delivered via secure video conferencing. I understand that the secure platform used meets all requirements of the Personal Health Information Protection Act, 2004 (PHIPA). As with all technology, while there are convenience benefits, I also acknowledge that there can be security risks to confidential information despite using a highly secure platform.

Our platform meets professional privacy and confidentiality standards. To access the video session, you simply need to click on the link emailed to you the day prior to your session. You enter your name to the prompt and then we will connect with you when your session is due to start. You do not need to download any application or install any software.

Technology Requirements

You will need a computer with secure internet access (e.g., not public Wi-Fi) and webcam ability. You will need a quiet, private space for your session time. You will also need access to a phone in the same room. You will need to provide your psychologist with your phone number and location. This ensures that if the video session is interrupted for any reason, we can switch to a phone connection to complete the session. Providing your location ensures that in case of a crisis or safety issue, your psychologist can send emergency help to your location. Please turn off any applications and notifications for the duration of your session. Ensure you have updated anti-virus and anti-malware software.

What Can My Therapist Provide?

I understand that my therapist is a professional who is able to work with me to determine my goals and make a plan to address barriers to achieving them based on evidence - supported therapy techniques. My therapist may assess symptoms and challenges but may not provide me with a diagnosis or documentation as to prognosis as this is outside of the scope for many psychotherapists. My therapist will create an individualized assessment and plan, and will help me learn new tools and techniques for reducing barriers to my goals. My therapist will check in with me regularly on how therapy is progressing and continue to tailor the approach to find what works best for me.

Tracking My Progress

It is useful for both myself and my therapist to track my progress to determine if adjustments need to be made to the therapy, or if things are progressing as hoped. One way of doing this is through periodically filling out questionnaires that reliably measure specific aspects of the issue that brought me to therapy.

In the Event of Crisis or Emergency

I understand that my therapist is not available for emergencies. Should I need to speak to someone immediately or find myself in the midst of a crisis, I agree to access services from my local emergency room or crisis intervention program as appropriate.

1. Confidentiality & Privacy

Your sessions are private. Information you share stays between you and your therapist.

By law, your therapist must share information in certain situations:

•If there is a risk of serious harm to you or someone else
•If there is suspected child abuse or neglect
•If required by a court order or legal authority

Under PHIPA, your therapist may share information with other health professionals directly involved in your care (“Circle of Care”). You can decline this, but it may affect how your care is coordinated. If you want your therapist to share information with people outside your care team, you will need to sign a separate consent form.

Your therapist may also consult with other therapists on their team for professional guidance. These consultations are confidential and meet PHIPA privacy standards.

2. Records & Documentation

•Your therapist will keep brief notes after each session (topics, progress, next steps).
•Records are stored securely in an electronic health record system that complies with privacy laws.
•Records are kept for 10 years after your last session (or 10 years after you turn 18, if you are a minor). After this time, they may be securely destroyed.
•You have the right to review your clinical record. A small fee may apply if you request a printed copy.
•Administrative staff may access limited personal information (like contact details) but not clinical notes.

3. Virtual Therapy

•Most therapy sessions are offered by secure video conferencing.
•The platform meets all PHIPA privacy requirements.
•While highly secure, no technology is completely risk-free.
•To join a session, you will receive a link by email. No downloads are required.

Technology requirements: A private space with a reliable internet connection, webcam, and phone access. Your therapist will ask for your phone number and location at the start of each session in case of emergency or technical issues. Please turn off notifications and close other apps during your session.

4. What Your Therapist Provides

•Your therapist will work with you to set goals and create a plan.
•They may assess challenges but may not provide a medical diagnosis or prognosis (depending on their professional scope).
•Therapy may include learning and practicing tools and techniques to support your goals.
•Progress will be reviewed regularly, and therapy adjusted as needed.

5. Emergencies & Crisis Support

Your therapist is not available for emergencies.

If you are in crisis, please contact:

•Canada: 988 (Suicide Crisis Helpline) or go to your nearest emergency department
•Local emergency services (dial 911 in urgent situations)

6. Clinical Training & Supervision

At times, practicum therapists (therapists-in-training) may provide services under supervision.

Your therapist may ask if an intern can observe or record your session for training.

7. Your Rights

•You have the right to ask questions at any time.
•You may withdraw your consent and stop therapy whenever you choose.
•Stopping therapy does not erase past records, but no new notes will be added after you leave.
•You will still be responsible for payment of past sessions.

8. Informed Consent

By clicking continue below, I confirm that:

•I have read and understood this form.
•I have had the chance to ask questions.
•I give my consent to receive counselling/psychotherapy services.
•I understand I may withdraw consent at any time.
•I agree that electronic consent is as legally binding as a handwritten signature.