A. Purpose and Nature of Treatment

1. Any information provided by the referral source about your claim was reviewed.
2. A clinical interview will be completed to assess psychological concerns.
3. Psychological questionnaires may be provided to further identify concerns.
4. Treatment recommendations will be made in a report to the referral source. The psychologist does not control the manner in which this report may be used.
5. If working with a treatment team, only information pertinent to your claim may be shared with team members to ensure best treatment practices. 

B. Mutual Responsibilities

1. Appointment time and dates will be scheduled for your convenience. 
2. The clinician will contact you as soon as possible in the event of sickness or a significant emergency.
3. You are responsible to contact the clinician 24 hours before an expected cancellation or, as soon as possible, in the event of sickness or a significant emergency.
4. Referral sources expect to be notified of missed attendance.
5. You have the right to end treatment at any time without prejudice from the clinician. Ending or refusing psychological treatment may nonetheless affect the course of your claim.

C. Roles

1. Psychological treatment may be facilitated by a registered psychologist
2. Psychological treatment may be facilitated by a provisional psychologist who is supervised by a registered psychologist.
3. You may request to meet with a registered psychologist.

 D. Confidentiality Protections and Limitations

1. Electronic documents pertaining to your claim are protected in a Lifemark limited-access server.
2. Psychological notes are kept in a locked and secured area.
3. Case notes and other documentation are deemed confidential and only available to those with a direct interest in your claim (e.g., Case Manager, Treatment Team).
4. Communication with referral sources may include report sharing, email communications, and case conferences. 
5. The report and any documentation belong to the referral source, but you have the right to request documentation about your file to the referral source. 
6. For all psychologists and provisional psychologists, the law requires confidentiality to end if any of the following situations apply:
   • Statements of intent to harm self or others
   • Statements indicating harm or abuse of children
   • Issuance of a court order

E. Risks and Benefits

1. For some individuals treatment may cause fatigue, frustration, or anxiety.
2. For most individuals treatment facilitates healthier patterns and increased life satisfaction.

This consent is valid for the duration of treatment. This consent can be rescinded by contacting the treating psychologist.