Informed Consent Form

Informed Consent Form

Welcome to my practice. I am happy you are here!
I am Hossein Haji Ghafari, a Registered Clinical Counselor with the BC Association of Clinical Counselors. I have prepared this letter to inform you about my policies, as well as your own rights as a counseling client. Please read it carefully before signing, and talk with me about any questions you may have.
As my client, first and foremost, you have the right to complete confidentiality. This is the foundation of a safe and effective counseling relationship. I will never share with anyone anything that you say to me, and I will not reveal to anyone whether or not you are a client of mine. You should be aware, however, that there are a few situations in which I cannot guarantee confidentiality, which are as follows. I would always let you know before taking any of the actions described below.
1) If I believe that you are at serious risk of suicide, I may legally break confidentiality in order to protect you. I would explore all other options with you before doing this, and if at that point, you were unwilling to take steps to ensure your safety, I would have to take action to make sure that you were protected from harming yourself.
2) If you tell me that you are seriously planning to hurt or kill an identifiable person, and I have reason to believe that you will follow through with it, I am legally required to try to inform that person to protect them from harm. I must also inform the police of your intentions.
3) If you tell me about a child or dependent adult who is being abused or neglected, then I am legally required to take steps to protect that child or adult by reporting this information to child protection authorities.
4) If you are involved in a court case and a request is made for information about our work together, I may ask you for written consent to disclose the requested information. I may be required to disclose information without your consent, but I will do all that I can within the law to protect your confidentiality. I will inform you of anything that I disclose.
5) If you request that I coordinate care with another care provider, I will get a signed release from you and discuss with you what information will be shared.
In order to protect your confidentiality, I will not acknowledge you if we run into each other in public. You are welcome to approach me, however.
You are free to talk about our professional relationship with whomever you choose.
In our first session(s), I will ask questions to try to get a sense of what brings you in to counseling/therapy. We will talk together about a plan for your time in therapy, and discuss what your goals are. I may ask you about things that you do not normally feel very comfortable thinking about, or feeling. You have the right to decide what you are comfortable sharing, and may choose not to discuss certain topics. However, sometimes it is helpful to push yourself a little and see whether some benefit may come from enduring the discomfort.
Counseling can have benefits and risks. Therapy can lead to better relationships, learning new ways to cope with or solve problems, developing new skills, reduction in feelings of distress, changing unwanted behaviors, and improved self- esteem. However, since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness and helplessness. There are no guarantees of what you will experience. Counseling is a process of personal exploration and may lead to major changes in your life perspectives and decisions. Together we will work to achieve the best possible results for you.
My counseling style is eclectic and responsive to client feedback. I include elements of developmental attachment theory, client centered listening and responding, cognitive therapy. If you have any questions about what is happening in therapy, please ask them. You also have the right to decline therapy at any time. If you ever find that you are unhappy about what is happening in your sessions, I encourage you to talk to me so that we can address your concerns. If you ever have serious concerns about me or about another RCC, you may contact the BC Association of Clinical Counselors.
My session fees are $168 per 1-hour session, unless we have negotiated a different sliding scale fee. Fees are payable by cash, cheque, credit card or e transfer at the start of each session.
If you need to cancel or change an appointment, I require 24 hours’ notice. Session fees will be charged for missed appointments and late cancellations.
If you need to reach me outside of our sessions, please use the number on this letterhead. You may email me, but please limit the use of email to scheduling issues. I do not use email for discussing personal material since it cannot be guaranteed confidential. I respond to all client phone calls and emails within 24 hours.
If there is an emergency, please call the Vancouver Crisis Line at 1-800-784-22073.
Client Consent to Psychotherapy
I have read this statement, had sufficient time to consider it carefully, asked any questions that I needed to, and understand it. I understand the limits to confidentiality required by law. I understand the fee per session, my rights and responsibilities as a client, and my therapist’s responsibilities to me. I know I can end therapy at any time I wish.

We will sign this form together on your first session.