PLEASE READ EACH ITEM AND CHOOSE YES OR NO:
______ I understand that Ms Josephine Smith is a counsellor and mediator - her qualifications are:
Change Birmingham Brief Therapy Diploma in solution focused therapy.
The Interpersonal Mediation Practitioner’s Certificate.
2. ______ I understand that Ms Josephine Smith does not provide 24-hour crisis counselling. Should I experience an emergency necessitating immediate mental health attention, I will immediately call 999 or go to an accident and emergency hospital department. or seek help from another organisation such as:
A. Samaritans. To talk about anything that is upsetting you, you can contact Samaritans 24 hours a day, 365 days a year. You can call 116 123 (free from any phone)
B. SANEline. If you're experiencing a mental health problem or supporting someone else, you can call SANEline on 0300 304 7000 (4.30pm–10.30pm every day).
C. National Suicide Prevention Helpline UK. Offers a supportive listening service to anyone with thoughts of suicide. You can call the National Suicide Prevention Helpline UK on 0800 689 5652 (6pm to midnight every day).
3. ______ I understand that this CPD is approximately 90 minuites in duration and it can be repeated.
4. ______ I understand that our contact will be limited to arranging and attending the CPD session, and that our relationship is a professional relationship rather than a social one.
5. ______ I understand that, at any time, I may initiate a discussion of possible positive or negative effects of entering of the CPD offered by Josephine Smith, and that specific results are not guaranteed although benefits are expected from the CPD..
6. ______ I understand that this CPD is a personal exploration of anxiety and it may lead to changes in my life perspectives and decisions. These changes could be temporarily distressing.
7. ______ I understand that the rate for the individual CPD session is £40.0 for up to a 90 minute session.
8. ______ I understand that there is no fee for cancellation or not attending. If I do not show up for an appointment and I wish to rebook the CPD it is my responsibility to make another appointment.
9. ______ I understand that it is my responsibility to take care of my health; to not attend the CPD if I am ill, and to be aware that I may fall over during the CPD, and to let Josephine know if there is any underlying health condition that might be affected by anxiety.
10. ______ I understand that I have the right to record my sessions, and I am solely responsible for maintaining the privacy of the recordings.
11. ______ I understand that while most of our communication is confidential there are, however, circumstances when disclosure can occur without my prior consent. The following are typical, but not exhaustive, examples of situations and circumstances under which information may be disclosed without prior consent:
As part of my ethical practice I have supervision from a more experienced therapist with whom I discuss my work. I never disclose my client’s name, and do not mention age or gender, so that the identity of my client is protected.
If you are a danger to yourself or someone else, I will seek advice and may need to break the confidentiality of our session.
In situations of suspected child, spouse, or elder abuse, it is my duty to notify medical, legal, or other authorities.
If you tell me that you are money laundering, trafficking drugs, or involved in terrorism it is against the law for me not to inform the police.
If you are involved in legal action/proceedings, your records may be subject to a summons or lawful directive from a court.