HEIDI SPIAR M.A. R.M.F.T Private Practice
AUTHORIZATION FOR FACE TO FACE COUNSELLING
I understand that by signing this form, I am entering into a therapeutic agreement. I also understand that my therapist will work with me to develop greater insight and awareness into my issue(s), help develop understanding and coping, and actively engage in steps that lead to solutions. I understand that therapy requires a willingness and motivation to examine parts of the issue(s) that cause distress, experience emotions about the issue(s) and engage in new behaviours to bring about resolution. I understand that my involvement is directly linked to the impact upon my successful outcomes.  I have been informed about the treatment process, expected benefits and risks.  I understand that as part of my treatment, additional referrals may be recommended to support my well-being.
Confidentiality:
In a face-to-face session that takes place in the office setting, the therapist is responsible to ensure privacy. For in-home service, the therapist and client share responsibility for choosing quiet place away from people not involved in the session  and to manage other interruptions. 
Information shared in a therapeutic session is private and restricted from sharing. If I want information shared with another person, professional or agency, I understand that I will be asked to sign a form indicating my consent. In this case, a summary and not the entire content will be provided, based upon what I want shared.  If I am attending counselling as part of a couple or family, or as a youth under 16 years, I wish for a parent to be involved, I must sign a form to share the information. If a youth attends counselling at the behest of a legal guardian, the information is confidential. With integrity and care, Heidi Spiar will do her best to encourage relevant sharing with a parent where fit and where a consent has been signed. Some situations limit or fall outside of the commitment to confidentiality. If this occurs, Heidi Spiar will use care and discretion while meeting legal and ethical obligations in the following cases:
•	When my therapist is ordered to provide information (such as with a subpoena) in writing or by verbal testimony
•	If information shared falls under the law requiring a mandatory report (example-child or elder abuse) where safeguarding information is not possible
Heidi Spiar uses an encrypted email account to protect you. It is your responsibility to ensure that your email account and other telecommunication hardware are safe. Unless otherwise arranged, sharing of identifiable, personal and lengthy information via email is discouraged. I thereby consent to corresponding by electronic mail if helpful for the purpose of general communication and that no confidential record will be sent in this way that could compromise my privacy without my consent.   (strike for no consent)         
Documents, storage and access:
I understand that Heidi Spiar will exercise confidentiality to collect and store records and that records are available upon request. Release of documents is free however clients are responsible for fees associated with transmission or postage. I understand that Heidi Spiar cannot guarantee the confidentiality of documents after they leave the office. If I wish Heidi Spiar to share information with another person, agency or professional that is relevant to my situation and could help my success, 
Safety of self and others:
At times, a client wants to reach a trained professional after hours and since this practice does not offer crisis service, an additional strategy for self-care is recommended. These situations will be discussed in session and an individualized plan for my protection can be created. If I feel unsafe at the hands of another person or if I wishes to hurt myself, I will be encouraged to seek emergency services in my own physical community. In rare, urgent cases where  risk to one’s self falls outside the realm of confidentiality, certain information from Heidi Spiar may be shared with  a crisis support or other emergency service to protect personal safety and life. 
Agreement:
By returning this agreement by one of the three options below, you are providing authorization for treatment and that you consent to the terms in the agreement. The receipt of the document will be interpreted as constituting a signature of consent to the terms set out in the document for ethical and legal purposes. 
1.	Print the agreement from the web page, complete and bring to the first session.
2.	Print the agreement from the web page, complete, sign and fax to: 905 471-2495
3.	Complete the form, save it, email as an attachment to Heidi@heidispiar.com. This option does not require a signature
4.	Complete and sign the form, copy and paste it into an email message to Heidi@heidispiar.com. This option does not require a signature 
____________________	____________________	____________  ____   ________
              Name of Client                                   Signature                                      Date                   Age    DOB M/D/YR

___________________    ____________________     ____________ (Leave blank if NA)
    Name of Legal Guardian                           Signature                                       Date