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Consent Form and Practice Policies

Office Visits: Payment is due at the time of service.  The fee is $225 per 50-minutes session.  Payment can be made by interac e-transfer (preferred) or check.  Credit card option available with extra $8 processing fee. 

Missed Appointments: If you need to re-schedule or cancel your appointment, please let me know with a 48-hour notice.  If you do not cancel within 48 hours, the full rate of your session will be charged (unless there is an unavoidable emergency).  I will do the same!  If I need to cancel our session I will notify you at least 48 hours in advance.  Otherwise, your next session will be free!
 
Telephone Contact Any conversation of a brief nature over the phone is included in the routine charge of sessions. If prolonged or repeated phone conversations are required, a fee appropriate to the time involved may be charged. Please request an available schedule of fees.
 
Email Contact Please be aware that confidentiality of email correspondence cannot be guaranteed. You should also know that any emails I receive from you and any responses that I send to you become a part of your record.
 
The Therapeutic Relationship:  Within the therapeutic relationship both parties have rights and responsibilities. As a client in psychotherapy you have certain rights that are important for you to know about. There are also limitations to those rights that are important for you to be aware of. The overall goal of therapy is the improvement of your wellbeing and I will make every effort to form a collaborative relationship with you in order to create the opportunity for optimal results. The process also requires active participation on your part. In essence we work as a team with each of us contributing. It should be noted however that I cannot provide a guarantee of results.
 
Confidentiality: With some exceptions, clients have the right to confidentiality and personal information about you will not be released to others including partners, spouses, parents, and physicians without your written consent. There are situations where psychologists are legally required to release personal information. Specifically, if you reveal information that indicates a clear and immediate danger to harm yourself or others, or that indicates a dependent adult or a child is in need of protection (a child in British Columbia is anyone under 19 years of age), I will need to contact appropriate authoritiesPsychologists are also required to release records if required to do so by court order and in some cases insurance providersIf a medical condition makes it unsafe for you to drive and you continue to drive a report must be made to the Superintendent of Motor Vehicles.  In an emergency situation, information may be shared with other care providers to ensure continuity of care. Clients have a right to be informed as to what transpired in these discussions.
 
Risks and Benefits:  There are risks and benefits to the therapeutic process. It often involves change, and change can often feel uncomfortable. Making changes in your beliefs or behaviors can be scary and sometimes disruptive to existing relationships. You may experience increased anxiety or sadness and things may feel as if they are getting worse before they get better. Therapy may involve the risk of remembering unpleasant events and may arouse strong feelings and discomfort. Benefits may include increased ability to live more effectively by improving your ability to cope with difficult situations, improved communication skills, decrease depression and anxiety and having a healthier and improved relationship with yourself and others. Risk and benefits will be different for different clients. Please take the time to discuss with me any concerns you have in this regard.
 
Treatment RecordsThe laws and standards of my profession require that I keep treatment records. You are entitled to a copy of the records unless I believe that seeing them would be emotionally damaging. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. Patients are charged an appropriate fee for any time spent in preparing any request for information.
 
Minors: If you are under nineteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that your work with me be confidential. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern.
 
Professional Consultation and Supervision
 There are times when I consult with professional colleagues to gain greater insight and feedback into my work. In these circumstances, no identifying information is given about you and colleagues are bound by the same limitations with respect to confidentiality as noted above
 
Length of Therapy and Termination: You normally will be the one who decides when therapy will end. Exceptions to this are if we have contracted for a specific number of sessions we will finish at the end of that contract. If in my judgment I am not able to help you because of the kind of problem you have or because my training and skills are not appropriate I will inform you of this and refer you to another therapist who may better meet your needs. If you threaten violence or verbally or physically harass me, my friends or family, I reserve the right to terminate the therapeutic relationship unilaterally and immediately.
 
Court TestimonyShould your treatment involve the need for me to testify in court please note that you are responsible for my time.  A schedule of fees related to preparation for court time as well as providing testimony is available.
 
Getting the Most from TherapyTherapy works best when a collaborative relationship is formed between the therapist and client in order to accomplish the goals established in the beginning of treatment. Your input is not only encouraged, but is a necessary component of the therapeutic process. You will get more out of the process if you are actively involved and engaged, come prepared to be involved in each session and by completing suggested homework between sessions.
 
Please feel free to discuss any of the above information with me at any point in time. If you have any questions or concerns or are unhappy with what is happening in therapy I encourage you to speak with me about it so that I can respond to your concerns. Complaints about psychologists can be made to the B.C. College of Psychologists. This is the regulatory body governing psychologists and provides information regarding laws, code of conduct, and guidelines governing the practice of psychology.  It is located at 404-1755 W Broadway, Vancouver B.C.
 
Telemental Health Therapy:   Telemental Health is used when therapy cannot be conducted in person, such as while you are out of town and request therapy, or during COVID-19.  Telemental Health therapy uses a video camera and computer to send audio, voice, and images.   It is best to set up your computer in a private room by yourself for the session.
 
The potential benefit of Telemental Health therapy is that you can continue counselling while out of town or while we are unable to meet for in-person sessions. 
 
The potential risk of Telemental Health therapy is that there could be a partial or complete failure of the equipment being used, which may lead to the inability to complete the session. All existing confidentially policies apply.   There is no video or voice recording of any kind during the session by you or Dr. Al-Mashat. 
 
You have the option to withhold consent at this time or withdraw this consent at any time. 

Electronic signature: