Dr. Earon Kavanagh, B.Sc., M.Sc., CPsychol, AFBPsS, MPCC
Canada Registered "Master Practitioner in Clinical Counselling", #4887
Office phone number (709) 699-3761; Email dr.earonkavanagh@proton.me
INFORMED CONSENT AND AGREEMENT FOR COUNSELLING
My “fee-for-service” counselling and psychotherapy private practice adheres to the Canadian Professional Counsellor's Association (CPCA) Code of Ethics, CPCA Standards of Practice, and CPCA's Ethical Framework and Guidelines for online counselling and psychotherapy. More information on these can be found at http://thecpca.ca/about-us-.aspx
CONFIDENTIALITY AND SECURITY:
The information shared with me is held in strict confidence and all notes and assessment information are stored in a locked filing cabinet. Information, including that you are my client, will only be released with your signed consent to release information.
EXCEPTIONS TO CONFIDENTIALITY:
In adherence with the CPCA ethical code, and Canadian laws, I am obliged to break confidentiality for the following:
• There is known, immediate, and/or life-threatening danger to the client or known individual;
• When there is reasonable suspicion of abuse or neglect of a child, elderly person, or vulnerable person;
• When the clinical counsellor, or client records, are subpoenaed by a court of law or judge.
YOUR RIGHTS AS A CLINICAL COUNSELLING CLIENT:
• You can ask about my credentials, clinical counselling services I am providing, and any other questions pertaining to counselling;
• You can ask for a review of your progress and any other items in this agreement;
• You can ask to be provided with a referral to another counsellor or health professional;
• You can withdraw consent to the collection, use, or disclosure of your personal information, except where precluded by law;
• You can end the counselling relationship by advising me of your decision;
* You can convey any of your concerns or complaints to myself.
• You also have the right to inform the CPCA of any unprofessional or unethical behavior by myself;
• You can have access to your personal information or ask for corrections to this information.
• Your right of access to, or to obtain a copy of your personal information continues after the end of the counselling relationship.
ONLINE COUNSELLING AND PROTECTING YOUR PRIVACY:
• I use the “Zoom for Healthcare” video meeting system, which is encrypted.
• I also use the encrypted “Proton” healthcare-grade email system.
• These methods are easy to work with, and I will guide you as needed. You do not need a webcam to use Zoom counselling.
USE OF EMAIL CORRESPONDENCE:
• I only use email to send encrypted documents and to make any appointments, etc.
• You will be guided in how to receive and open protected emails and forms. This is a relatively easy, and your privacy is protected.
THERAPY SESSION TIME-LENGTH:
• Standard counselling/therapy sessions are 50-minutes. This meets the need for most clients. It also allows an extra 10 minutes for notes.
• Longer sessions are available by client request
• Psychological/Psychometric testing – will also include any additional costs for the tests used.
• Please note: All sessions start on time and end promptly, whether client is on-time or late.
FEES:
• A standard individual session is $130.00 (50 minutes);
• Couple and family sessions are $160.00;
• Discounted sessions - 10% discount if pre-paid before the session;
• Therapeutic letters, which document your progress, are available, require written permission, and are $60.00 each;
• Telephone consultations are available at $2.20 per minute;
• All fees add a 15% Harmonized Sales Tax (HST);
• Canada Revenue Agency may allow personal tax deductions for counselling therapy. Please verify this with your tax advisor;
• My professional fees are reviewed and updated on an annual basis .
Fees for other related professional services
• Email correspondence ($2.20 per minute);
• Review or drafting documents and preparation ($2.20 per minute);
• Travel time to and from meetings ($2.20 per minute);
• Mileage related to above travel ($.60 per kilometer);
• Meeting attendance on your behalf (non-court): $130.00 per 50 minutes
• Additional fees on (above) meeting attendance - time fees for preparation, travel time fees, and mileage fees.
LEGAL MATTERS SUCH AS COURT INVOLVEMENT:
• Clients entering into counselling therapy, agree to not involve me in legal or court proceedings, unless otherwise agreed to.
• Nor will clients attempt to obtain file records when marital or family counselling has not been successful at resolving disputes.
• Testimony or other involvement in a court proceeding requires your written consent.
• If you subpoena me to produce counselling therapy records, or appear at a hearing, the fee is $250.00 per hour...
• Plus HST for all time, and charges incurred in any legal proceeding, whether or not I actually testify in a legal proceeding.
CANCELLING A SESSION or NON-ATTENDANCE OF BOOKED SESSIONS:
• Cancellations require a 24-hour notice.
• If the cancellation period is less than 24 hours, I will bill you in full for the missed session.
• “No-shows” to any session also result in you being billed for the full session.
• To cancel a session, email me at dr.earonkavanagh@proton.me.... or leave a message at my practice (709)699-3761.
LATE ARRIVALS TO SESSIONS:
• If you are late to a session, whether online or in-person, the full appointment fee is still charged, and the session ends at prescribed time.
PAYMENT OF COUNSELLING FEES:
• Payment is required by the end of the date on which the session was delivered, by INTERAC e-transfer, PAYPAL;
• The INTERAC e-transfer information and PAYPAL details are made available once you become a client (also see website .
• Payments for Office-based local sessions: payment is in cash at the end of the session.
• If you pay in cash, please bring the exact amount. I cannot provide change.
• If you pay electronically anytime ahead of the session you receive a 10% discount.
SESSION FEES AND HEALTH BENEFITS PLANS:
• Your health benefits plan may reimburses all or a portion of the fee for clinical counselling services;
* In such cases, you pay my fee, receive my professional receipt, and then seek reimbursement from your Plan provider;
* To receive reimbursement, you will need to submit the receipts to the plan administration office;
• For information on using your health insurance plan for counselling fees, visit your Plan Provider website (or plan manual), or phone them.
• Have your plan number ready to find out if your plan covers “clinical counselling”;
* Your health plan may or may not reimburse you for the full cost of clinical counselling services that you have paid;
• You remain responsible for any additional costs and I will not refund the difference.
• Clinical counselling services not covered by health plans may be tax deductible as a medical expense.
* To confirm Canada tax deductions for clinical counselling as medical expense, please consult with your tax advisor.
UNPAID SESSION FEES:
• No other sessions will be provided until session fees are paid.
OUTSTANDING FEES:
• Missed session fees, admin fees, and unpaid session fees must be paid within 15 days.
• After 15 days these owed amounts are automatically turned over to a collection agent.
COUNSELLING, AND ASSESSMENT OF CRISIS:
• My private practice, specializing in person-centered talk-therapy, does not provide full-service crisis response.
• If you experience “crisis” such as suicidal ideation or extreme emotional distress please call the following...
• Mental Health Crisis Line (709) 737-4668, or Toll Free 1 (888) 737-4668. Free services and very professional.
• You can also call “9-8-8”, or visit your local hospital emergency ward.
• Signs of crisis may be feelings or thoughts about suicide, or harm to yourself or another.
• If you, or someone you know are in immediate danger, please call 9-1-1 (Newfoundland and Labrador emergency help line)
TERMINATION OF COUNSELLING:
• At the end of our counselling agreement a record of our exchanges will be stored on file in a locked cabinet, for a period of 7 years.
• No identifying names or material is retained on these records, as a client ID number is used.
• After this time, paper documents will be shredded.
CONDITIONS OF COUNSELLING:
• I ask that you do not record, on audio or video, any of the content of our sessions or consultations, without my prior agreement;
• Email will not be used as a counselling or consultation mode;
• I will support you fully...to declare when you are ready to terminate the counselling relationship,
• I will support you fully, and co-create a plan should you choose to take a break from clinical counselling
• I will support you fully to seek a therapist more suitable for your needs, and assist with a referral.
CONTACT ME ON MY ENCRYPTED EMAIL SYSTEM IF YOU HAVE ANY QUESTIONS SUCH AS BELOW
• If you are seeking further contact about my services;
• If you have questions on this informed consent and agreement for counselling;
• If you are seeking further information or wish a 15 minute free consultation
• CONTACT: dr.earonkavanagh@proton.me
If interested in booking an assessment session, Email me to confirm that you have read this informed consent and that you consent to participate in clinical counselling.
• Please note that this is a webpage version of the Informed Consent and Agreement for Counselling
* The complete and signable version can be downloaded from here onto your computer