Client Informed Consent
Informed Consent for Psychotherapy Services
Welcome to Heartful Psychotherapy. We look forward to assisting you. In Heartful Psychotherapy your therapy sessions will be done alongside our licensed psychotherapist, Alexander Louis B. Kierulf.
Individual psychotherapy sessions are typically set for a duration of 45 minutes and will be scheduled in collaboration between you and the psychotherapist. It is important to note that maintaining a consistent day and time for sessions may not always be possible due to the high demand for our services. If you ever need to cancel or reschedule an appointment, kindly inform us as early as you can so that we can offer the available slot to someone else. Please understand that missing appointments or making last-minute cancellations within 48 hours of the session may result in a cancellation fee equal to the full session fee. For non-session communication needs, we often use email to connect with clients. However, please be aware that email is not a secure means of communication. If you have any concerns about using email in this way, feel free to discuss it with your psychotherapist.
II. Purpose of Psychotherapy
IV. Fees and Payment
Heartful Psychotherapy sessions are provided at a fee of¥7,700 (Includes 10% tax). By agreeing and signing this consent form, you are agreeing to pay the session fees.
V. Benefits and Risks
VI. Termination of Therapy
VII. Records and Documentation
At Heartful Psychotherapy, it is mandatory for us to maintain appropriate records of the psychotherapy services rendered. Your records are securely stored within our office premises. These records encompass concise notes, including session dates, your reasons for seeking therapy, treatment objectives and progress as determined collaboratively between you and the psychotherapist, topics covered during sessions, your medical, social, and treatment history, any records received from other healthcare providers, copies of records sent to third parties, as well as billing records.
Except in exceptional circumstances involving potential harm to yourself, you possess the right to request a copy of your records. It’s important to note that as professional records, they may be complex and potentially distressing for individuals without specialized training to interpret. Consequently, we recommend that you initially review them with your psychotherapist or have them shared with another qualified mental health professional for discussion.
In the event that we decline your request for access to your records, you have the prerogative to seek a review of our decision by another mental health professional, a process we can discuss further upon your request. Furthermore, you retain the right to request that a copy of your records may be made available to any other healthcare provider, subject to your written request.