Client Agreement and Personal Details Form
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Information About Services
Personal Information:
As part of providing a counselling service, I will need to collect and record personal information about you that is relevant to your current situation. This information will be a necessary part of the assessment and counselling that is conducted. Any such information, along with correspondence to me and my session notes, will be kept in a file and stored securely in a locked filing cabinet or electronically password protected.
Confidentiality:
All information collected will remain confidential except when:
• It is subpoenaed by a court; or
• You are at risk of harming yourself; or
• Failure to disclose would place you or another person at risk
As a counsellor I attend supervision and your case may be discussed with my supervisors. If I do, your name is not used, but some of your background details may be shared with the supervisors to ensure the best possible care for you.
Couples Counselling: Couples counselling requires a ‘balanced alliance’ which means that I do not take sides and will challenge and support you both, acting as an objective facilitator to what you need to explore together. Once couples therapy has commenced, in most instances I do not conduct sessions with either of you separately. When individual therapy would assist the couples counselling process, I generally refer out to another counsellor (unless we all agree I am the best counsellor to see and we talk through possible issues that may arise). Therapy does not work effectively if I’m asked to keep secrets or information is revealed to me privately that is of significance to the trust and health of the relationship. If I am approached about such an issue, I will encourage you to bring it up in session and will offer you support to reveal and navigate the issue. If I feel that I cannot continue therapy unless an issue is revealed, and in doing so will breach confidentiality, I will discuss with you the need to cease counselling.
Fees:
Consultations are 50- 60 minutes in duration.
There is a $150 fee for individual counselling or $200 fee for couples counselling or a pre-agreed $110/$160 taking into consideration other circumstances such as hardship and mode of counselling (online versus room hire).
Group or family counselling fees depend on the number in the group. If you are unable to attend a scheduled counselling appointment and fail to notify me 24 hours prior to the appointment, a fee of $50.00 will be charged.
Payment can be made in cash at the conclusion of your session; using the SquareUp EFT system to issue an invoice or tap at the appointment (requires a credit or debit card) or via direct debit transfer before or after your session.
My account details are:
Sara Martin, ANZ
BSB: 014221
A/C: 329257389
Appointments:
I have allocated times for session scheduling and sometimes have a waiting list. If you need to cancel your appointment, please notify and discuss this with me as far in advance as possible. I require a minimum of 24 hours’ notice of a cancellation of your scheduled appointment. If you fail to notify me of cancellation of your scheduled appointment or are a “no show” to the appointment, you will be charged a cancellation fee. If you do not attend three sessions in a row, your counselling and appointment time may be forfeited. I can make suggestions for frequency of sessions, but ultimately the duration of counselling is up to you and you have the autonomy to choose the frequency of sessions and when you want to finish or take a break. I’d appreciate you discussing this with me so that I can accommodate other clients. You will be provided at least one- week notice (unless circumstances are unforeseeable) when I take a break or if there is a change to a regular appointment time. I will ask you for the same notice of breaks and termination.
Qualifications & Limitations:
My qualification is a Master of Counselling and I am involved in ongoing professional development. I am registered with the Psychotherapy and Counselling Federation of Australia (PACFA) and also with the Christian Counsellors Association of Australia (CCAA) for those clients who specifically want Christian beliefs considered in their self-examination. I am also able to explore other spiritual belief systems and your worldview will be respected at all times.
If I feel that we encounter an area that I do not feel qualified to assist you, I may suggest other counselling options or referral pathways to assist with our counselling. If I need to formally refer or am requested for a report, I will discuss this with you, gain your consent and only disclose relevant information.
My clinical hours are Tuesday – Friday from 9am to 7pm and I am unavailable when in session and after hours and on weekends. I am unable to provide a crisis counselling service. If you are distressed and need immediate attention outside of my clinical hours, you can contact Lifeline on 13 11 14. If you feel suicidal, please contact 000 immediately or the Suicide Call Back Service on 1300 659 467.
Some other helpful lines include Kids Helpline: 1800 551 800 (for young people 5-25), Parentline: 1300 30 1300 (for parents 8am-10pm 7 days), and Beyond Blue: 1300 224 636.
*Please take care to fill out the emergency contact section of my form. I cannot break your confidentiality and speak to any person who contacts me on your behalf unless you have specifically specified their name, thus providing consent.
How Counselling Operates:
Counselling is a mutual, collaborative process. I work in a holistic way and we will explore your health and wellbeing; the influence of your family and social systems; your biology; social interactions; psychological state; and lifestyle, spirituality, or worldview. These are all elements that make up why you are who you are, and understanding yourself is the key to working out what you want in life.
We will work together to develop goals on which you want to work. I cannot change you, but act as a facilitator. Only you can change yourself and take responsibility for the choices you make and the effort to work on the concerns you have. I am committed to helping you in this process. No therapist can guarantee certain results. There are some risks associated with counselling, such as discovering things about yourself that are uncomfortable; sometimes, relationships change as a result of your choices and growth. Sometimes, traumatic memories can arise and feelings get more intense. I can assure you I will use my professional skills to navigate these issues with you and manage possible risks. I may refer you to other specialists if I feel it may assist you in your therapy.
When you are working with me, it is important to honour the commitment you have made to attend sessions and to take an active role. For example, it is helpful if you: (1) spend time between scheduled sessions thinking about what we have explored; (2) follow through on any suggestions of therapeutic interventions/activities; (3) take the initiative to bring up issues or topics to talk about with me.
If you are experiencing any problems or difficulties relating to me, I encourage you to discuss these with me and we will attempt to reach some resolution. Sometimes we may decide that it is best for you to meet with another therapist.
Complaints:
I am bound by the Code of Ethics of the professional associations I am registered with. If there is a grievance with me, I am registered with PACFA and you may contact them to discuss your concerns at https://www.pacfa.org.au/contact-us/
Please refrain from being under the influence of drugs and alcohol when attending counselling, this would be grounds for termination of the session.