Psychotherapy Contracting & Intake form
Please review the following Psychotherapy contract and intake form. You may choose to fill out your details here or else in person during your initial psychotherapy session (If you have opted for online sessions, then please do complete the details on the intake form). We really look forward to working with you.
Welcome. The following contract serves as an agreement between you and your therapist, highlighting the structure of the therapy sessions. Please take a few minutes to read the contract and feel free to ask any questions you may have during your initial session.
Duration of Session
The duration of each therapy session is 50 minutes. Sessions will begin and finish at the previously agreed time.
Payment
Payment can be made at the time of booking your session online, at the beginning or at the end of each session.
Payment can be made in cash or by credit/debit card if booking online or engaging in online therapy sessions. Payment can also be made by Electronic Fund Transfer (please ask for bank details if you wish to make payments this way).
Two months notice will be given for any changes in fee.
Cancellations or Change of Appointment
48 hours of notice is required if you cannot make a session. In the event that less than 48 hours of notice is given, every effort will be made to find an alternative appointment within that week. However, if no alternative time can be found, the session fee is still due.
Termination of Therapy
When possible, 3 weeks’ notice will be given before either the therapist or the client terminates therapy as this helps to bring about a healthy closure to the process.
Confidentiality
All client information is confidential except in emergencies or in circumstances relating to the Children First Act, 2015, in the Republic of Ireland.
Your therapist meets with a supervisor, but does not use full client names.
Your therapist does not provide medical or legal reports.
In the very rare situation that your therapist feels there is a risk to your life or that of someone else, your therapist may contact your next of kin, the relevant authority or your GP. When possible, this action will be taken with your knowledge.
Length of Psychotherapy and Ongoing Reviews
Your psychotherapy should last for a minimum of 6 sessions. Many clients wish to continue far beyond that, sometimes for several years.
Ongoing reviews of continuing the psychotherapeutic relationship will be initiated by your therapist on a regular basis. However, you are welcome to ask for a review of the therapeutic process at any stage.
Retention and Succession of Client Records
Notes will be kept for a period of 10 years after your therapy finishes. However, this period of time is subject to the provisions of the Data Protection Act, 2018, which specifies that your notes will be kept for ‘as long as is necessary’, be that more or less than 10 years.
In the event that your therapist is suddenly unavailable for any further session (e.g. for reasons ranging from serious illness to death), you will be informed by their Professional Executor. This person will have access to your name and your phone number. In the event that you should require access to your client notes, a request can be made in writing to the Professional Executor and they will follow all necessary protocols, in line with GDPR legislation, to provide you with same.
Privacy Notice
In line with the European General Data Protection Regulations (GDPR), and as a practitioner registered with the IACP, I am obliged to share the following information regarding how your data is protected:
Data Storage
Intake Forms
Intake forms collect the following information:
Name and contact information
Name of emergency contact and contact information
Previous history of therapy and medical history
Intake Forms and all data containing your own contact information, your designated emergency contact information and your GP’s contact information will be held in a secure Google Drive document. The Google Drive account is password protected and accessed via a password protected laptop or iPhone. The data you enter in the online Intake Form will be emailed to a secure Gmail-based business email account that uses the Gmail authentication security protocol. This account is accessible by phone and laptop, which are password protected. The data contained within this emailed version of the Intake Form will be transferred to a secure Google Drive document which is part of a Google Drive account and, as mentioned above, it is password protected and accessed via a password protected laptop or iPhone.
Correspondence
Any correspondence by email is stored within a Gmail-based business email account and uses the Gmail authentication security protocol. This account is accessible by phone and laptop, which are password protected. Text messages are stored on a password protected phone. Messages that are sent using iMessage are also accessible on a laptop through iCloud.
Invoices
Conexus Psychotherapy uses the online booking system acuityscheduling.com and the online credit card payment website squareup.com. Conexus Psychotherapy does not have access to your credit card details, but will have access to your name and contact details, as provided by you through these websites.
Throughout the duration of therapy your invoice will be electronically updated on an ongoing basis. The invoice records the date of each session and the cost of each session. The invoice document is password protected on an encrypted device. Invoices will be emailed either on a session-by-session basis or else on an aggregated basis, dependent upon what you and your therapist agree during your first session. Where you choose to pay online by credit card via Stripe payment software, you will be directly sent a copy of your Stripe invoice. If you do not book and pay for sessions online, your invoice will be sent to you on a regular basis.
Session Records
A digital record of each session’s notes is kept. This document records the date of each session and also records any follow-up points needed. Any notes that relate to the content of each session are recorded digitally in a password protected Google Drive file and accessed on an encrypted device. These notes are anonymised.
Sharing of Information
In line with best psychotherapeutic practice, the profession, names and phone numbers of current clients are shared with a Professional Executor(s). This person/people would contact you in the event of an emergency, for example if your psychotherapist is unable to make personal contact with you.
Your data will not be shared with a third party unless Conexus is legally obliged to do so. In this highly unlikely event, unless there was a legal prohibition, you will always be informed first.
All data and information is destroyed ten years after your therapy has come to an end. (Although notes will be kept for a period of 10 years after your therapy finishes, this period of time is subject to the provisions of the Data Protection Act, 2018, which specifies that your notes will be kept for ‘as long as is necessary’, be that more or less than 10 years.)
It is a legal requirement to seek your consent in order to store all of this data. By typing your name below and clicking Submit, you are consenting that Conexus Psychotherapy may store all of the data that is outlined above.
Intake Form
Please complete the following intake form. you may choose to fill out your details here or else in person during your initial psychotherapy session. (Reminder: if you have opted for online sessions, the please do complete the details of the following form online. Thank you.)