Counselling Consent Form

Name

Email Address

Contact number

Name of the Counsellor

I understand that there are some limits to confidentiality and these include: 1. If there is a reasonable suspicion of child abuse 2. If there is a reasonable suspicion of serious elder abuse 3. If there is a reasonable suspicion of serious bodily harm to myself or someone else 4. If I disclose an intention to commit a serious crime 5. If the counsellor is ordered by a court of law to release information 6. If the counsellor’s notes are subpoenaed by a court of law 6. If the counsellor’s notes are subpoenaed by a court of law 7. If the counsellor is required to release information to a professional regulatory body

I understand that the counselling process is confidential and that information will not be shared with anyone without my written consent

I understand that the counselling process is voluntary and that I may withdraw my consent at any time.

I understand that I am responsible for my own wellbeing and that of my family and that I may need to seek additional support outside of counselling if I feel that my wellbeing is at risk.

Signature

Date