Informed Consent for Psychological Therapy
Before starting psychological therapy, it is helpful to understand what is involved in therapy and what is special about E-Therapy. Read the following material carefully, and indicate your agreement with the terms if you choose to continue. Remember that you can stop therapy at any time should you later change your mind or circumstances change.
Participating in E-Therapy sessions with Dr. Anastasia Barbopoulos is as if you are participating in a therapy session with Dr. Barbopoulos in an office in the jurisdiction of Manitoba, Ontario, Saskatchewan, or Alberta, Canada.
Age. You must be 18 years of age or older.
Privacy.
Unless prior approval is granted by both Dr. Barbopoulos and you, only you and Dr. Barbopoulos will be present for your sessions, and sessions will not be recorded.
For E-Therapy, Dr. Barbopoulos generally uses SKYPE or FaceTime. SKYPE and FaceTime send voice and visual information over the Internet using encryption to complicate interception of messages. As with all long distance communication, however, rare security concerns do exist. By consenting to E-Therapy with Dr. Barbopoulos via SKYPE or FaceTime, you accept the security concerns.
Confidentiality.
Information about sessions is confidential except where you authorize Dr. Barbopoulos to communicate with others or the Limits of Confidentiality apply, including:
A. Risk of imminent danger to you or another person, Dr. Barbopoulos is ethically bound to take necessary steps to prevent such danger. In such a case the local police department would be notified.
B. Suspicion that a child is being sexually or physically abused or is at risk of such abuse, Dr. Barbopoulos is legally required to take steps to protect the child or elder, and to inform the proper authorities.
C. When a valid court order or subpoena is issued for medical records, Dr. Barbopoulos is bound by law to comply with such requests.
Limits of E-Therapy.
Some mental health issues (e.g. psychosis, mania, serious suicidal ideation, dissociation, active symptoms of Posttraumatic Stress Disorder) cannot be addressed effectively through E-Therapy and require local face-to-face assessment and treatment. E-therapy is also not appropriate for dealing with such crises as child protection, reactions to traumatic events, sexual assault, or thoughts about harming others.
Missed or Disrupted Appointments.
If you decide to cancel an appointment, please give 24-hour notice to allow Dr. Barbopoulos time to schedule other clients. Without 24-hour notice, you will be charged the session fees. If E-Therapy is disrupted and cannot continue due to technological failure, Dr. Barbopoulos will contact you at the phone number you have provided unless informed otherwise.
Responsibilities and Potential Risks.
Psychotherapy provides benefits, but there are also risks. Specifically, therapy may elicit uncomfortable thoughts and feelings, or may lead you to remember troubling events. Dr. Barbopoulos will assist you in engaging in self-exploration and decision-making but any decisions or actions taken as a result of therapy, remain solely your responsibility.
Fees.
Regular 50 minute sessions cost $170 for In-Office therapy or E-Therapy (Canadian funds). For E-Therapy a 20-minute first time session free of charge can be available upon request. Sessions can be one time consultations or ongoing, depending upon your needs. You only pay for one session at a time. You may be reimbursed if you have a health-care plan that covers psychological services. Discuss potential coverage of In-Office psychological therapy or E-Therapy with your health care insurance provider.
Response to Referral Source and Progress Reports.
If you have been referred for psychological services by your physician or other professional, a letter will be sent confirming that you have had an initial consultation and whether psychological intervention will follow. Progress reports can also be sent at your request and will be reimbursed at the rate of $170 per hour for the amount of time required to write the reports.
In case of emergency.
Dr. Barbopoulos will contact the person you have identified as your emergency contact if your psychological health deteriorates and you require more support than can be provided to you through e-therapy and/or become a danger to yourself or others. If you experience a life-threatening crisis, you agree to contact a crisis hotline in Manitoba, Saskatchewan, Alberta, or Ontario, or call 911, or go to a hospital emergency room.
