Mental Health Service Agreement Informed Consent and Authorization
Counselling Approach and Services
The Mental Health services of RFHT are client-focused, skills-based, and goal-oriented approaches. Counselling services provided include assessments and counselling to individuals ages 16+, who are dealing with issues related to mental health and emotional well-being. Additionally, the Social Worker/ Psychotherapist/ Psychologist provide information, education, and referrals/linkages to other appropriate community resources.
Clients can access up to a maximum of 8 individual counselling sessions through RFHT Mental Health Services. The number of sessions will be determined with the social worker/psychologist or psychotherapist, based on the client’s needs, goals, and progress. The client’s involvement in counselling is voluntary and the client can withdraw from the service at any time.
- If a client is a no-show for two appointments, or misses/cancels an appointment but fails to contact the office to reschedule within 3 months of their missed or cancelled appointment, the client will be discharged from the mental health Program
- RFHT has limited resources to be able to continue to provide free access to counselling services. Therefore, if a client does not require all 8 sessions within a 6-month time frame, the client will be discharged from mental health services. Clients who require counselling in the future are able to request an intake assessment 18 months from their last session.
- As part of the mental health intake process, all clients are required to complete a mental health service agreement informed consent and authorization form prior to their first counselling appointment.
Parameters OF Mental Health Services:
- Clinical services are not designed to support complex/long-term support/services. Clinical services are through a Trauma-Informed Lens that is not long-term treatment. Clients who are currently engaged in case management or other counselling/therapy services are ineligible to access counselling during this same time frame.
- Not all clients who request counselling will be eligible. Some clients may have needs that are too complex to be treated within the parameters of service (please see attachment: Additional information for criteria exceeding services).
- Mental health services are offered as part of an individual’s mental wellness support system. If you choose to participate in RFHT mental health services, you understand and agree that if your needs are/or become greater than the scope of mental health support services that services can no longer be offered, and you will be referred to and encouraged to engage with your current and/or additional mental health support system.
1) Personal Health Information Protection Act, 2004 (“PHIPA”)- Your personal information and data are treated with utmost confidentiality as required by the PHIPA
2) CONFIDENTIALITY - When receiving mental health services at Rapids Family Health Team, all personal information will be kept confidential. However, the following are examples when a client’s personal information may be shared:
- When the client signs a consent form or provides verbal consent to allow for information to be shared.
- When the Social Worker/Psychotherapist/Psychologist is required by law to share confidential information.
- When the Social Worker/Psychotherapist/Psychologist must communicate with other allied health professionals for the purpose of providing the client with appropriate assessment and treatment services.
- The information shared with other allied health professionals will be held in strict confidence in accordance with Rapids Family Health Team policies and procedures. The therapist will maintain the best interest of the client as their primary professional obligation.
3) Safety is of the upmost importance in the therapeutic working relationship. Both parties have the right to safe and respectful communication within session, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, and national origin.
4) WRITTEN CONSENT is required for any information to be disclosed to a third party (other than court subpoena). Any information to be disclosed would be discussed with you and agreed upon by both you and your clinician. The one exception to this would be should the courts subpoena a client’s clinical file. You may review the contents of your own counselling file on request.
5) DUTY TO REPORT Confidentiality is limited by conditions imposed by law when a client discloses the following:
- Reports or threatens to harm themselves or another person;
- The Social Worker/Psychotherapist/Psychologist has reason to suspect that a young person (under the age of 16) has been or is currently being abused or at risk of abuse or neglected.
This may occur when:
- when domestic violence is reported and there is a child (children) in the home;
- the client discloses that he/she was abused in childhood and there is a possibility that the abuser may be a danger to the children now;
- The courts subpoena the client’s clinical file.
Under these conditions, the therapist will let the client know that they have a professional “duty to report” the information they have received to the appropriate authorities, including Parent/guardian/caregiver, medical professional or emergency personnel, the person who is at risk, Children’s Aid Society and /or Police.
6) COMMUNICATION and SOCIAL MEDIA
It is of utmost importance that your confidentiality is maintained, and that your boundaries, and relations with RFHT remains professional. Therefore, RFHT has the following expectations in place:
- (a) Cell phones & Texts: Please note that staff are not permitted to use text messaging to communicate with clients. Should there be any reason to discuss any part of your participation with RFHT, this is to occur within hours of operation of RFHT. Please do not attempt to communicate via text messaging,
- (b) Email: Emailing is not a secure means of communication and may compromise your confidentiality. However, realizes that many people prefer to email because it is a quick way to convey information. Only email staff during regular business hours, for appointment rescheduling, or cancellations. To prevent compromising your confidentiality, please do not bring up any specific details in the content via email to. Emailing for appointments or changes will only be responded to during business hours. Your email messages will be responded to within 5 business days, unless however, a staff member is on an extended leave due to illness or vacation.
- (c) Social media Policy: RFHT staff cannot accept requests from any current or former clients on social networking sites such as Facebook, LinkedIn, Instagram, etc. because it may compromise your confidentiality. RFHT also ask that you also agree not to write any negative comments/ reviews regarding RFHT, services provided, or on any/all forms social media or any other platforms on the world-wide web. To address any concerns, you have regarding your care with our agency, you agree to bring your concern directly to the social worker to endeavor to try to resolve try your matter.
7) RECORDINGS The audio or video recording of any kind, during participation with RFHT staff is absolutely prohibited without permission and the written consent of the staff and yourself as a client of RFHT.
8) Virtual sessions are conducted using the Doxy Me platform. This is a virtual online host and is NOT an encrypted virtual online platform that meets PHIPA and HIPAA privacy standards.
Understanding that this is a technology-based service, there remain risks including risks to privacy as these technology-based modalities are not guaranteed to be secure. Cellphone, Virtual, Text, and email are not secured for privacy, and it is possible that your information can be hacked. There have been instances in other industries where highly secured virtual venues and online systems have been intruded. By signing this consent form, you agree to accept the risk of the use of technology-based modalities.
RFHT mental health services are NOT a crisis service, for clients who intend to harm themselves or others, have homicidal thoughts, or major psychiatric episodes. Should you have any of these symptoms, you agree to contact your primary care provider, hospital, or a crisis service. If you are at risk of suicide, immediately contact 911 or go to your local hospital emergency department.
