ELECTRONIC COUNSELLING CONSENT FORM
I am choosing to do all or some of my counselling sessions via the internet using the Zoom program with my counsellor. By choosing this option, I understand that:
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• Zoom is an online communication tool allowing for face-to-face video or voice dialogue. Zoom-to-Zoom calling is encrypted.
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• Zoom software must be downloaded onto a computer and an account setup.
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• I agree to add my counsellor’s username to my contacts.
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• Appointments will be made via email or phone appointment request. I agree to be online at least five minutes prior to session, alone, in a quiet room, door closed. The counsellor will call at the scheduled appointment time.
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• For best Zoom picture and audio quality, I undertake to get expert computer advice if needed. I understand that my counsellor is not a computer expert.
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I also understand the following limitations of Zoom video therapy sessions:
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• Any internet-based communication is not 100% guaranteed to be secure and confidential. I agree that my counsellor, should not be held responsible if any outside party gains access to Zoom’s personal or confidential information by bypassing their security measures.
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• I understand that my counsellor does not provide emergency services. In a crisis or emergency situation that needs immediate attention, whereby I am considering seriously harming myself or someone else, I will call the Toronto Distress Centre 416-408-4357, dial 911 or go to a mental health hospital/ER. I understand that there are limits to the scope of a counsellor, and that I may need to be referred to a fully regulated mental health professional if a serious disorder develops.
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• Confidentiality will be treated like an in-office session: no outside distractions, turn off cell phones, be alone in the room (e.g. no children or other adults present) close other programs on computer and be on time. I understand that I must give 24 hours notice to cancel or change session times. If I do not give this notice, I understand that I need to pay for the session time.
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• Technical problems could occur. If the call is disrupted, the counsellor will call back within ten minutes. If reconnection cannot occur, the session will be rescheduled through email or phone contact. If technical problems occur and the counsellor and I are not able to solve them, I understand that I will not be charged for the session time.
