HEIDI SPIAR M.A. R.M.F.T Private Practice
VIDEO AND PHONE COUNSELLING AUTHORIZATION FOR COUNSELLING
Telecounselling (video and phone) is becoming a more commonly used mode of counselling. While the therapist and client “meet” at a distance, the commitment to deliver high quality service is consistent with the more traditional, face-to-face delivery method. As with other forms of counselling, tele-service requires a motivation and commitment on your part to discover the specific parts of an issue that causes distress, to experience the emotions about the issue and engage in new behaviour that leads to resolution. In the first session, Heidi Spiar will review the contents of this authorization for treatment and ensure that I understand what I signed.  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:
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. 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, and 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. 
In a face-to-face session, the therapist is responsible for the privacy of the session. In telecounselling, the therapist can only ensure confidentiality from her end and the client is responsible for the privacy on the client’s end of the call. Telecounselling clients often find a quiet place away from family members, co-worker or strangers to manage interruptions. Clients who choose to conduct the session in a public place waive the privilege of  confidentiality and are responsible for the protection of information.
Heidi Spiar uses an encrypted email account to protect you. You are responsible to ensure that your email account/telecommunication hardware is safe. Unless otherwise arranged, sharing of identifiable, personal and lengthy information via email is discouraged.
Documents, storage and access:
I understand that Heidi Spiar will exercise confidentiality to collect and store records. I understand 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. 
LIMITATIONS to confidentiality: 
Heidi Spiar will use care and discretion while meeting legal and ethical obligations
a.	When my therapist is ordered to provide information (such as with a subpoena) in writing or by verbal testimony
b.	If information shared falls under the law requiring report (example-child or elder abuse) where safeguarding information is not possible. 
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 wish to hurt myself, I will seek emergency services in my own physical community. Rare cases of an urgent matter where  risk to one’s self falls outside of confidentiality, certain information from Heidi Spiar may be shared to protect personal safety and life. 
Agreement:
I agree to telecounselling service by phone or electronic face to face (ie, Skype).By completing and returning this agreement by one of the three options below, I give authorization to the terms for telecounselling with Heidi Spiar. I choose one of the following options 48 hours before the first session: 
1.	Print the agreement from the web page, complete, sign and fax to: 905 471-2495
2.	Complete the form, save it, email as an attachment to Heidi@heidispiar.com. This option does not require a signature
3.	Complete and sign the form, copy and paste it into an email message to Heidi@heidispiar.com. This option does not require a signature 
____________________	____________________	____________ ___   _________
          Printed Client Name	                             Signature                                        Date               Age      Date of Birth
 ___________________    ____________________     ___________(ignore if not applicable)
          Guardian Name                                     Signature                                         Date