Therapeutic Agreement




Address---------------------------------------------------------------------------------------------------------------------------Post Coded-----------------------------------


Contact nos.----------------------------------------------------------------------------------------------------------------------Consent to leave message YES/NO


Next of kin (relationship, name -------------------------------------------------------------------------------------------------------------------------------------------


----------------------------------------------Contact no.--------------------------------------------------------------------------Consent to leave message YES/NO


Dr`s surgery name and contact no.-------------------------------------------------------------------------------------------------------------------------------------


I have read, understood and kept the current client information document titled “Could Psychological Therapy Help You?”.


I confirm I am making an informed and autonomous decision to undergo a psychological assessment and subsequent treatment, if applicable.


I understand I need to give a minimum of 24 cancellation notice if I am unable to attend an appointment. Non attended appointments or late cancellations will count as sessions taken, unless due to exceptional* circumstances.


I understand if I need urgent support or deem myself/others at risk between sessions I need to contact my GP, NHS on 111, the Samaritans or the emergency services on 999.


I understand I can choose to terminate my therapeutic agreement at any-time. However if an appointment has been confirmed I am required to give a minimum of 48 hours- notice otherwise full charges will apply.


I understand the therapist may make and keep written and/or computer notes in accordance with clinical practice and current legislation. The records are kept, stored or destroyed in accordance with the current data protection legislation and the requirements by professional bodies.


I understand that anything I disclose to the therapist is strictly confidential between myself and the therapist. The therapist may sometimes discuss with their Clinical Supervisor, in strictest confidence, some of the issues which may arise out of my therapy. This is a standard requirement set down by the UKCP and BABCP professional bodies to ensure safe practice. However, there are circumstances when the confidentiality agreement may be overridden and they are as follows:


•If in the therapist’s professional judgment I am a serious risk to myself, to/from others, the therapist has duty of care to contact the appropriate services on my behalf. I may or may not be informed or their action beforehand.


•If I disclose something which may suggest to the therapist that a child or a vulnerable adult is at risk, not necessarily from me but someone else. The therapist will seek advice from another professional/agency before acting. I may or may not be informed of their action beforehand.


•If I disclose something which may suggest to the therapist that a specific individual or the general public are at risk from criminal activities but not necessarily from me, the therapist will seek appropriate professional advice before acting. I may or may not be informed of their action beforehand.


•Or if I willingly give the therapist my written consent to release my information to a 3rd party and accept the related outcome.


Signature----------------------------------------------------------------------- Date-----------------------------------------------------------


* For the purpose of this contract exceptional circumstances mean if the patient is hospitalized for any health reason. Or the patient is considered incapable of making the journey to the clinic for physical health reasons and can provide a medical note to the effect.