MindTherapies

Therapeutic Agreement

Name----------------------------------------------------------------------------DOB----------------------

 

Address----------------------------------------------------------------------------------------------------

 

GP ---------------------------------------------------------------------------------------------------------

 

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 consider psychological therapy.

 

I am aware I can terminate my therapeutic agreement at anytime but shall be required to give a minimum of 48 hours notice.

 

Non attended or late cancellations will count as sessions taken unless due to exceptional* circumstances. The full cost will have to be met by whoever pays for my therapy.

 

I am aware I am responsible for ensuring there is sufficient funding available from my health care insurance company for my treatment. Any costs beyond and above the fund available I shall pay myself.

 

I understand the therapist may make and keep written and/or computer notes in accordance with clinical practice and UK legislation. The records are stored in accordance with the current UK data protection legislation.

 

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, BACP 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 but unable to seek my GP`s help. The therapist may contact my GP on my behalf but I shall be informed of their action.
  • 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 hospitalised 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.