*Note: This is only an example of items you can include. It’s recommended you work with a lawyer to understand your rights and create a personalized document for your practice*

Our Health Providers

Shrutee Sharma, Feldenkrais Practitoiner certified by the Feldenkrais Guild of North America

Ethical Standards

As members in good standing with each of their respective colleges. Shrutee Sharma abides by their codes of ethics and is accountable to each of their governing bodies for ethical and professional standards.

Records

Records are kept for each client and kept for a minimum of ten years. Your file may contain any brief session notes from private sessions we have together, if applicable. This enables us to provide you with the best care possible.

You are welcome to review your file at any time. No records will be shared with any other parties without your signed permission on a ‘Consent for Release & Exchange of Information’ form. It is your choice whether information is released and you are not required to sign any consent if you are not comfortable with it.

Confidentiality

Everything that is said via email or in the context of the conversations between service provider and client is kept confidential. There may be times when consultations may be made with another therapist or health professional. This is similar to a physician getting a “second opinion” and can be very helpful in therapeutic treatment. If consultation does occur, identifying information such as your surname will not be disclosed.

There are a few exceptions to confidentiality which you should be aware of:
1. When the client gives written permission (a signed release form) to have information from the counseling sessions communicated to another person.

2. When the client is at risk to hurt themselves or others, as when there is danger of suicide or assault.

3. When there is reason to believe that a child has, is, or may be in danger of sexual or physical abuse or neglect. 

This includes:

- When domestic violence is reported and there is a child or children in the home. 

- When a client discloses that he/she was abused in childhood, there is a possibility that the abuser may be a danger to other children now. In these situations I am legally bound to report to Family & Children’s Services
4. When mandated by a court order:

At times it may be suggested that I make contact with other professionals or family members in order to obtain information that will be helpful in your treatment. A signed ‘Consent for Release & Exchange of Information’ form is required and you have the right to refuse your signature. Should information be requested by anyone outside of my office, you will be notified. If it is not an emergency situation, then signed consent is required and the person/agency requesting the information will not receive it, or be informed you are attending sessions, until the proper signature is received from you. If it is an emergency situation you will be informed via telephone, email or in person, as soon as possible. An emergency situation would be an urgent police, medical or child protection situation. Should there be proceedings before the courts and your records are subpoenaed you will be notified as soon as possible.

Your Rights

As a client you have the right:

1. To ask questions at any point in time regarding therapeutic or program procedures.

2. To terminate the program at any time; you may ask me for a list of possible referral sources. (Please see the Refund Policy.)

3. To be informed of any information, decisions and actions that will affect you.

4. To ask about alternative procedures available for meeting your goals.

5. To review all documentation in your client file.

6. To complain to the Privacy Commissioner of Canada If you are not satisfied with the Privacy Policy in place.

Refund Policy

Refunds will be processed after deducting the full charge of services that have been availed of. Refunds for programs will only be issued if you are dis-satisfied with your progress inspite of having completed the programs within the suggested time frame and remedial measures to offer additional support have been taken.

Program Length & Fees

Fees for this program are due in full or in part according to our payment plan.  Payment can be made via credit card only.

Informed Consent

By clicking below, I agree that I have read and understand the above information, and agree to the terms of therapy stated above. My Service Provider(s) has adequately answered any questions I have at this point in time (via email).

I understand I have the right to stop following the program at any time, and may ask for a list of referral sources. I understand that it is usually best for Service Providers and clients to make joint decisions about termination of treatment.

My signature indicates that I am giving my consent for Shrutee Sharma to counsel & support me. I will make a copy of this for my records.