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
III. Confidentiality
- 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
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.
VIII. Treatment of a Minor
- 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.