Client Informed Consent

Informed Consent for Psychotherapy Services

Therapist: Alexander Kierulf
Practice Name: Heartful Psychotherapy
Contact Information: therapy@heartfulpsychotherapy.com
Website: heartfulpsychotherapy.com

I. Introduction

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

Psychotherapy is a collaborative process between the therapist and the client, aimed at addressing various psychological, emotional, or behavioral concerns. The goals of therapy may include, but are not limited to, improving mental health, enhancing self-awareness, developing coping strategies, and achieving personal growth.

III. Confidentiality

In adherence to Japanese law, we want to clarify the concept of confidentiality and its exceptions at the beginning of your psychotherapy. We invite you to review this information and address any questions you may have. All interactions with our psychotherapist are held in strict confidence. Our team will not disclose any details about you to your parents, friends, family, administrators, or others without your explicit consent, except under the following circumstances:

A. Heartful Psychotherapy reserved the right to breach the confidentiality of your conversations if you express intentions of harming yourself or someone else, and there is a reasonable concern that you may act on this intention. In such cases, the psychotherapist may arrange for your assessment by a psychiatrist or clinician in a hospital setting. It may also become necessary to contact your family members or others who can assist in ensuring your safety. In situations involving threats or actual violence toward another person, the psychotherapist has a legal obligation to take protective actions, which may include informing the potential victim, security personnel, and/or the relevant law enforcement authorities. Psychotherapists are considered mandated reporters, and they are obligated to break confidentiality be reporting to the appropriate agency if you disclose that a minor (under age 18), an elderly person, or an individual with a disability is experiencing abuse.
B. Conversations held during psychotherapy sessions are legally privileged, meaning you have the right to prevent the clinician from testifying in most legal proceedings, even if a subpoena is issued. Exceptions to this privilege may apply when a judge mandates testimony in specific legal cases, such as when a client has passed away, or in situations involving child custody and adoption proceedings, lawsuits in which your mental health plays a significant role, legal proceedings related to psychiatric hospitalization, malpractice or disciplinary actions against the psychotherapist, and court-ordered psychological evaluations.

IV. Fees and Payment

Heartful Psychotherapy sessions are provided at a fee of ¥5,000 (Includes 10% tax). By agreeing and signing this consent form, you are agreeing to pay the session fees.

V. Benefits and Risks

Psychotherapy offers both advantages and potential challenges. Some potential challenges may involve encountering uncomfortable emotions like sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness. This is because the psychotherapy process often involves discussing difficult aspects of your life. Nonetheless, psychotherapy has demonstrated positive outcomes for those who engage in it. It frequently leads to notable reduction in distress, improved satisfaction in personal relationships, heightened self-awareness and understanding, enhanced coping skills for managing stress, and solutions to specific issues. However, it is important to acknowledge that outcomes cannot be guaranteed. The effectiveness of psychotherapy largely depends on your active participation and effort.

VI. Termination of Therapy

Please acknowledge that therapy may be terminated at any time by either you or the therapist under just and reasonable circumstances, such as but not limited to endangering the safety of either the therapist or the client, non-payment, therapist’s professional judgment, client’s voluntary decision, and client’s reluctance. The therapist will discuss the reasons for termination if it becomes necessary.

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.

VIII. Treatment of a Minor

If you are under 18 years of age, your parent or legal guardian must provide consent for your treatment. Heartful Psychotherapy retains the right to inform your parent(s) or legal guardian about any developments that could significantly impact your health or well-being. In such cases, while the specific details of your sessions with the psychotherapist will remain confidential, your overall progress may be discussed in general terms. Heartful Psychotherapy may disclose certain information without your consent to either your parent(s) or legal authorities under the following circumstances:

1. If you convey to your psychotherapist that you intend to cause serious harm or death to yourself or someone else, and the psychotherapist believes that you have the immediate intent and capability to carry out this threat. In such cases, the psychotherapist must take measures to inform a parent or guardian about what you have shared and the seriousness of the threat. If you plan to harm someone else, the intended victim may also be informed.
2. If your actions have the potential to cause serious harm to yourself or someone else, even if there is no intention to harm. In such situations, the psychotherapist will exercise professional judgment to determine whether a parent or guardian should be notified.
3. If you disclose to your psychotherapist that you have experienced physical or sexual abuse or that you have been a victim or abuse in the past. In this scenario, the psychotherapist may be obliged to report the abuse to the appropriate authorities or law enforcement. Additionally, during a child abuse investigation, Heartful Psychotherapy may need to allow a child abuse team to access and copy client records without the consent of the child or the child’s parent/guardian.
4. If you are involved in a legal case, and there is a request for information about your counseling or therapy. If this situation arises, your psychotherapist will not disclose information about you or your parents without their written agreement, unless compelled to do so by a court order. Heartful Psychotherapy will make every effort, within the bounds of the law, to safeguard your confidentiality. If the psychotherapist is required to disclose information to the court, you will be informed of this occurrence.

EXCEPTION: Parental or guardianship consent may not apply if a parent declines involvement, if there are clear clinical reasons to the contrary, if the minor has been a victim of sexual abuse by a parent, or if the minor is legally emancipated. However, exceptions to confidentiality may still apply to legal authorities in the event any of the aforementioned circumstances arises.

IX. Consent for Treatment

I voluntarily consent to participate in psychotherapy with Alexander Louis B. Kierulf at Heartful Psychotherapy. I have read and understood the information provided in this Informed Consent form, and I have had the opportunity to ask questions.