The Mind Space Consent Form

Please read and review the consent form below.

Not a Crisis Service

I understand that The Mind Space is not a crisis service. In the event of a mental health crisis or emergency, I acknowledge that I should seek immediate assistance from emergency services or contact a crisis hotline for support. In case of emergency, I may contact:

  • 911 for immediate assistance;
  • the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or text “HELLO” to 741741 for the Crisis Text Line.
  • the National Suicide Prevention Lifeline at 988

If necessary, The Mind Space may contact my designated emergency contact or emergency services on my behalf.

Psychotherapy

Purpose: I understand that the purpose of psychotherapy is to explore personal issues, set goals, and develop coping strategies to address challenges and improve overall well-being. I acknowledge that psychotherapy is not a guarantee of specific outcomes.

Approach to Treatment: Understanding the therapist’s approach to treatment is essential for clients considering psychotherapy services. The therapist’s theoretical orientation or modalities used can significantly impact the therapeutic process and outcomes. Here’s an overview of The Mind Space’s approach to treatment:

Theoretical Orientation: The therapists at The Mind Space are trained in various theoretical orientations and modalities, allowing for a tailored approach to meet each client’s unique needs. If clients have questions or seek further clarification about the therapist’s theoretical orientation or treatment approach, they are encouraged to discuss it with their therapist during sessions.

Flexibility and Integration: While therapists may have a primary theoretical orientation or modality, they also integrate elements from other approaches to best meet the client’s needs. This flexible approach allows therapists to adapt their strategies based on individual client characteristics and presenting concerns.

Tailored Treatment Plans: The therapists at The Mind Space work collaboratively with clients to develop personalized treatment plans based on their specific needs, preferences, and goals. This client-centered approach ensures that treatment aligns with the client’s values and promotes active engagement in the therapeutic process.

Client Progress Tracking and Treatment Adjustment: At The Mind Space, your therapist is committed to monitoring your progress throughout your therapy and making adjustments to your treatment as needed. This includes:

  • Regular assessment of your goals, challenges, and progress during therapy sessions.
  • Collaborating with you to evaluate the effectiveness of interventions and strategies.
  • Flexibility in adapting treatment approaches to better suit your evolving needs and circumstances.
  • Open communication about any changes in treatment direction or goals.
  • Ensuring that therapy remains aligned with your objectives and promotes your overall well-being.

Therapist’s Qualifications: The therapist providing psychotherapy services at The Mind Space possesses qualifications including education, training, and experience relevant to the field of psychotherapy. They have undergone rigorous training in psychotherapy modalities and techniques and continue to engage in ongoing professional development to enhance their skills and knowledge. The therapist’s qualifications ensure that they are equipped to provide high-quality care and support to clients seeking psychotherapy services.

Diagnosing Limitation: I understand that the therapist providing psychotherapy services at The Mind Space is not authorized to provide medical diagnoses. If I require a medical diagnosis, I will be referred to an appropriate healthcare professional.

Risks of Psychotherapy: I understand that psychotherapy may involve potential risks which may include, but are not limited to:

  • Emotional Discomfort: Discussing difficult emotions and experiences in therapy sessions can sometimes lead to increased distress before improvements are realized. Clients may experience uncomfortable emotions such as sadness, anger, or anxiety during the therapeutic process.
  • Strong Emotional Reactions: Exploring past traumas or challenging current beliefs and behaviors may evoke strong emotional reactions. It’s essential to be aware that therapy may not always feel comfortable, and progress may occur gradually.
  • Side Effects or Adverse Reactions: In some cases, individuals may experience side effects or adverse reactions to psychotherapy, such as heightened anxiety or temporary worsening of symptoms. These effects are typically temporary and subside as therapy progresses.

Potential Benefits of Psychotherapy: I understand that psychotherapy may involve potential benefits which may include, but are not limited to:

  • Improved Well-being: Psychotherapy can lead to improved overall well-being by helping individuals develop coping strategies to address challenges effectively.
  • Enhanced Self-awareness: Through therapy, individuals can gain a deeper understanding of themselves, their thoughts, feelings, and behaviors.
  • Improved Relationships: Therapy can help individuals develop healthier relationships and improve communication skills.
  • Increased Resilience: Learning effective coping strategies can enhance resilience and help individuals navigate future challenges more effectively.

Termination of Therapy: The therapist reserves the right to terminate therapy with the client at any time if they believe it is not in the client’s best interest or if the client poses a risk to themselves or others. In such cases, the therapist will provide alternate solutions or referrals to ensure the client’s ongoing care needs are met. The decision to terminate therapy will be discussed with the client during a scheduled session, and the therapist will work collaboratively with the client to ensure a smooth transition out of therapy.

Ending Therapy: If a client wishes to end therapy, they are encouraged to discuss their decision with their therapist during a scheduled session. The client may choose to terminate therapy at any time, and it is their responsibility to inform the therapist of their decision. The therapist will respect the client’s decision and work collaboratively to ensure a smooth transition out of therapy, which may include discussing any remaining goals or unresolved issues.

Liability: I understand that while every effort will be made to ensure the effectiveness and safety of psychotherapy services, The Mind Space and its therapists cannot guarantee specific outcomes or results. I acknowledge that I am voluntarily participating in psychotherapy services and assume any associated risks.

Complaints to CRPO: If you have any concerns or complaints about the psychotherapy services provided by a therapist, you may contact the College of Registered Psychotherapists of Ontario (CRPO).

Confidentiality Policy

Confidentiality: I understand that all information shared during therapy sessions is confidential and that there are limits to this confidentiality. The Mind Space adheres to the confidentiality standards outlined by the College of Registered Psychotherapists of Ontario (CRPO) and relevant legislation, including but not limited to the Personal Health Information Protection Act (PHIPA) and the Health Care Consent Act.

Limits to Confidentiality: I understand that there are limits to maintaining my confidentiality as my therapist is obligated to comply with the legal requirements as mandated by the CRPO. I understand that if the following requirements are met, my therapist is legally obligated to disclose my information with others, if there is:

  • a suspected or imminent risk of harm to myself;
  • a suspected or imminent risk of harm to others;
  • suspected or imminent risk of child abuse; or
  • a court order mandating disclosure of information.

Consultation and Supervision: I understand that the therapist may engage in consultation with other mental health professionals for the purpose of improving the quality of care provided. Additionally, my therapist may receive supervision from a qualified supervisor to ensure adherence to ethical and professional standards. I acknowledge that any information shared during consultation or supervision will be done so while maintaining confidentiality as required by law and professional ethics.

Right to Withdraw Consent: I understand that I have the right to withdraw consent for treatment at any time. I acknowledge that if I choose to withdraw consent, it may affect the continuation of my psychotherapy services at The Mind Space.

Informed Consent and Health Care Consent Act: I understand that my participation in psychotherapy requires informed consent, as outlined in the Health Care Consent Act. I acknowledge that I have been provided with information about the purpose, risks, benefits, and alternatives to psychotherapy, and I have had the opportunity to ask questions and receive satisfactory answers.

Scheduling Policy

Scheduling Process: At The Mind Space, we prioritize convenience and flexibility when it comes to scheduling appointments and determining appointment times. Here’s an overview of our process:

  1. Initial Contact: When you reach out to us to schedule an appointment, you may use our online scheduling calendar to help you find a suitable time slot based on your availability and preferences.
  2. Intake Assessment: Before your first session, you’ll undergo an intake assessment to gather relevant information about your needs, goals, and scheduling constraints. This assessment helps us tailor our services to meet your unique requirements. You will also be asked to provide The Mind Space with the information needed to open your client file.
  3. Intake Appointment: During your first appointment, your therapist will confirm the information you entered in your intake form. Your therapist will also review the consent form with you. Your therapist may also collect additional information to open your file or to begin treatment.

Determining Appointment Times: Appointment times vary, but generally depend on the following factors.

  • Client Availability: We take into account your availability and preferred times when determining appointment slots.
  • Therapist Availability: Appointment times are also influenced by the availability of our therapists.
  • Mutual Agreement: Appointment times are ultimately determined through mutual agreement between you and your therapist. We understand that life can be busy, so we strive to find a time that works for both parties and allows for consistent, uninterrupted therapy sessions.

Payment, Insurance, Cancellation, and Missed Appointment Policy

Payment Agreement: I understand that psychotherapy services provided by The Mind Space are subject to fees. The fee amounts will be discussed and agreed upon between myself and The Mind Space prior to the commencement of services. I acknowledge that payment is due at the time of service unless otherwise arranged.

Sliding Scale Fee Structure: At The Mind Space, we offer a sliding scale fee structure to accommodate varying financial situations. This means that the cost of therapy is flexible and based on your financial circumstances. Your support enables us to maintain our commitment to affordability and accessibility for all. We’ll work with you to determine a fee that’s fair and affordable for you, while also promoting a sense of community and support within our practice.

Sliding Scale Renegotiation: At The Mind Space, we understand that financial circumstances can change over time, affecting your ability to afford psychotherapy services. Therefore, clients may have the option to renegotiate their sliding scale fee if their financial situation changes significantly. If you find that you are facing financial hardship and need to adjust your fee arrangement, please discuss this with your therapist. We are committed to working with you to ensure that therapy remains accessible and affordable, and we will explore options to accommodate your needs to the best of our ability. All adjustments to the sliding scale fee must be mutually agreed upon, and The Mind Space reserves the right to make all final decisions regarding fee renegotiation.

Fees and Insurance: I understand that I may be eligible for insurance coverage for psychotherapy services, and it is my responsibility to verify coverage with my insurance provider.

Direct Billing and Insurance: I understand that The Mind Space may offer direct billing services for eligible insurance providers. I authorize The Mind Space to submit claims on my behalf and to receive payment directly from my insurance provider for psychotherapy services rendered. I acknowledge that it is my responsibility to provide accurate and up-to-date insurance information and to understand my coverage and benefits.

Cancellations: I acknowledge that appointments must be cancelled at least 24 hours in advance to avoid a cancellation fee. I understand that failure to cancel within the specified timeframe may result in a charge to my account. I acknowledge that cancellation fees are equivalent to the full session price.

Missed Appointment: I understand that failure to attend a scheduled appointment without prior notification may result in a no-show fee being charged to my account. I acknowledge that missed appointment fees are equivalent to the full session price.

Receipts and Insurance Submission: Clients understand that receipts for psychotherapy services will only be provided for completed sessions. If an appointment is cancelled or missed, a receipt will not be issued, and the session will not be submitted for insurance reimbursement. In such cases, the client is responsible for paying the entire session fee directly.

How to Reschedule If you need to cancel or reschedule an appointment at The Mind Space, please follow these instructions:

  1. Contact your therapist as soon as possible by phone or e-mail to notify them of any changes to your scheduled appointment.
  2. Please be aware of our cancellation policy: appointments must be cancelled at least 24 hours in advance to avoid a cancellation fee.
  3. Your therapist will work with you to find a suitable alternative appointment time, if necessary.

Additional Fees: I understand that there may be additional fees for services such as writing confirmations of attending therapy or summaries. The fee amounts for these services will be discussed and agreed upon between myself and The Mind Space prior to the provision of these services.

Information Management and Security

**Keeping Information:**Clients are advised to keep a copy of this consent form for their records. Additionally, clients may request access to their therapy records at any time in accordance with the PHIPA. The Mind Space will provide information about the process for accessing therapy records upon request.

Retention of Information: I understand that therapy records will be retained for a period of 10 years following the termination of therapy, after which they will be securely destroyed in accordance with applicable laws and regulations.

Accuracy of Information: I confirm that all information provided to The Mind Space, including personal details, medical history, and current circumstances, is accurate and complete to the best of my knowledge. I understand that providing false or misleading information may compromise the effectiveness of therapy and agree to update The Mind Space promptly in the event of any changes to my information.

Access to Records: Upon request, clients are entitled to review the contents of their therapy records maintained by The Mind Space. This includes session notes, assessments, and any other documentation related to their treatment. Clients can submit a written request by e-mail to access their records, and our team will respond promptly to arrange a convenient time for review.

Requesting Corrections: If you believe that any information in your therapy records is inaccurate, incomplete, or outdated, you have the right to request corrections. Simply submit a written request by e-mail specifying the details of the information you believe should be corrected, along with any supporting documentation or evidence, if necessary. Our team will carefully review your request and make appropriate updates to ensure the accuracy and integrity of your records.

Use of Telehealth Platform: I understand that psychotherapy sessions will be conducted using a secure telehealth platform approved by The Mind Space. I acknowledge that while teletherapy employs measures to ensure the security and privacy of our sessions, there are inherent risks associated with online communication. I consent to the use of the telehealth platform for conducting psychotherapy sessions.

Information Protection: The Mind Space is committed to protecting the confidentiality and security of client information. All therapy records are stored securely and accessed only by authorized personnel. The Mind Space implements safeguards to prevent unauthorized access, disclosure, or alteration of client information. Additionally, The Mind Space adheres to the standards set forth by the CRPO and relevant legislation, including but not limited to the PHIPA, and the Health Care Consent Act, regarding the collection, use, and disclosure of personal health information.

Technology Requirements and Communication Policy

Technology Requirements: For optimal teletherapy sessions at The Mind Space, ensure you meet these technology requirements:

  • Stable internet connection
  • Compatible devices: desktops, laptops, tablets, and smartphones
  • Reach out to our technical support team for assistance with any technical issues or questions

Respectful Communication: Clients are expected to engage in respectful communication with The Mind Space staff and therapists, whether in person, over the phone, via text, or e-mail. Any form of abusive language, harassment, or disrespectful behavior will not be tolerated. Clients understand that engaging in such behaviour may result in the revocation of services or termination of therapy.

Protection of Private Information: Clients are advised against sending private or sensitive information over text or unencrypted email. While The Mind Space takes measures to ensure the security of electronic communication, there is a risk of interception or unauthorized access. Clients are encouraged to discuss sensitive matters during therapy sessions or through secure channels provided by The Mind Space.

Timely Response: I understand that while The Mind Space will make every effort to respond to communication via e-mail or text message in a timely manner, there is no guarantee of a fast response or a response at all. I acknowledge the limitations of electronic communication and understand that urgent matters should be addressed by contacting The Mind Space directly by phone.

Intellectual Property Rights

The client acknowledges that all materials provided during therapy sessions, including but not limited to written documents, assessments, and treatment plans, are the intellectual property of The Mind Space. The client agrees not to reproduce, distribute, or copy any materials provided to them without prior written consent from The Mind Space. This includes sharing materials with third parties or using them for commercial purposes. Any unauthorized use or reproduction of intellectual property may result in legal action.

Changes to Agreement

The Mind Space reserves the right to make changes to this consent agreement as needed. Any modifications will be communicated to the client in a timely manner.

Last updated: May 2024