Declaration

I am over 18 years of age. I am currently living in English Canada, or I am a permanent resident of English Canada.
In the past year I have not threatened or planned suicide or homicide, engaged in self-harming behavior such as
cutting or burning, had a mental health emergency, used drugs other than marijuana illegally, had a sexual
relationship with a minor (unless the authorities already know about it), been involved in domestic violence as abuser
or victim, or been involved in violent or organized crime. I do not work in law enforcement or in any occupation that
requires me to be armed. I am aware that my counsellor does not do reports or write letters for custody. I agree that,
should I be involved in legal proceedings, neither I nor my lawyer(s), nor anyone else acting on my behalf will call
on my therapist to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless it is by mutual consent.

I agree to pay for each session by Interac 48 hours in advance if it is in the office or 24 hours in advance if it is online, unless another arrangement has been made ahead of time.

I live in British Columbia OR (use drop down below). While I do not anticipate that I will have a mental health crisis, I have prepared a crisis reference list, which I keep for ready reference on __Cell Phone__ (eg., fridge, cell phone) [The list should include 911 and the phone numbers of the local crisis line and/or other local emergency service, any clinic
where you are enrolled, any friends or relatives who might be able to help, a local taxi service if there is one, and the address of the nearest hospital emergency entrance.] I am attaching this list along with this form to the email
message (or mailing it if mailing a hardcopy of the form).

Cancellation

I will pay for any in-office session cancelled less than 24 hours in advance for any reason or for any online session cancelled less than 24 hours in advance unless some other arrangement has been agreed upon ahead of time.

Emergencies

I understand that my counsellor does not provide emergency services, though I am aware that I am encouraged to
inform him/her by email of any crisis or of any upsetting after-effects of a session. Informed Consent: I am aware that treatment for any disorder or dysfunction requires my informed consent, which I can withdraw at any time, and that I
am encouraged to ask any questions I may have about how a treatment works, the expected results, any risks,
alternative treatments, or the likely results of no treatment.

Confidentiality and Records

I am aware that my counsellor advises clients that counselling usually works better if they do not reveal the content
of their sessions to family or friends, especially within 24 hours of the session. I am aware that my counsellor will not
be able to maintain confidentiality when he/she is obligated by law to do otherwise, or when he/she believes that
someone is in danger of bodily harm. I also understand that the use of communication technology can compromise confidentiality. I agree that when doing individual sessions in the context of couple therapy it is my responsibility to
make it clear what information, if any, should not be shared with my spouse. I am aware that the notes on my sessions constitute a medical record which has to be retained by my counsellor for the mandated number of years, but that
the first session is exploratory, and notes on it will not be preserved if I do not continue. In order to protect my
counsellor's privacy, I will not share any electronic or other records I may have of our work together without her
written permission.

Use the below drop-down box to certificy that you have read and understand this form and that all information is correct.