Informed Consent – Relationship Counselling

Purpose of collecting infor mation

• As part of providing a professional psychological service to you, I will need to collect and record personal information from you that is relevant to your current situation.

• The information is retained in order to document what happens during sessions, and enables me to provide a relevant and informed psychological service.

• You do not have to give all your private information, but if you don’t, this may mean the psychological service may not be able to be provided.
  

Confidentiality

• You have the right to the confidentiality of the information that you share. Subject to certain limited exceptions (described below), your personal information is kept strictly confidential and stored securely, at all times.
  

• Records are kept digitally at  www.halaxy.com. Halaxy is protected by 256-bit bank grade security and encryption, which means records, notes and personal information is protected to the same level used in banks. All information is encrypted and stored in a securely protected data centre in Australia with multiple backups in place. All paper documents are securely destroyed.
  

Exceptions to Confidentiality

• There are exceptions in which psychologists will exercise their duty to waive confidentiality. This can occur when:

  • The information you have given is subpoenaed (officially requested) by a court of law;

  • Failure to disclose the information would place you or another person at risk; or

  • Your prior approval has been obtained to:

    • provide a written report to another professional or agency. e.g. a lawyer; or

    • discuss the material with another person, e.g., a parent or employer.
      

• During couples counselling, there is a clear ‘no secrets’ policy (see below)
  

'No Secrets' Policy

• When a couple enters into counselling, it is considered to be one unit. This means that my allegiance is to the couple “unit,” and not to either partner as individuals. I find this is particularly important in creating a space where both partners can feel safe. Therefore, I adhere to a strict “No Secrets” policy. This means that I will not hold secrets for either partner. This policy is intended to allow me to continue to treat the couple by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated.
  

• On occasion during the counselling process, individual partners may be seen for an individual counselling session. In this case, the individual session is still considered as part of the couple’s counselling relationship. Information disclosed during individual sessions may be relevant or even essential to the proper treatment of the couple. If an individual chooses to share such information with me, I will offer the individual every opportunity to disclosethe relevant information and will provide guidance in this process.

• If the individual refuses to disclose this information within the couple’s session, I may determine that it is necessary to discontinue the counselling relationship with the couple. If there is information that an individual desires to address within a context of individual confidentiality, I will be happy to provide referrals to therapists who can provide concurrent individual therapy. This policy is intended to maintain the integrity of the couples/marital counselling relationship.
  

Court Proceedings/Subpoena of Records  

• The purpose of relationship therapy is for the amelioration of distress within a relationship. Therefore, if both partners request my services as a psychologist, they are expected not to use information given to me during the therapy process against the other party in a legal setting of any kind, be it civil or criminal.

• Likewise, neither party shall for any reason attempt to subpoena my records or subpoena me to appear at any court hearing of any kind for any reason, such as a divorce case or Family Law matters pertaining to your children. 

Exchange of Information

• There may be times where, as part of the assessment and therapy process, it may be helpful to liaise with other people or agencies that are relevant to your goals. Additional consent forms will be requested in these instances.  

Access to Information

• At any stage, you are entitled to access to the information about you kept on file, unless the relevant legislation provides otherwise. The psychologist may discuss with you appropriate forms of access. You have a right of access to information held about you in accordance with the Privacy Act 1988 and the Freedom of Information Act 1982.
  

• Requests for access should be made in writing.
  

• Both partners must provide their consent to release relationship counselling records. If one partner does not provide consent, records will not be released.
  

• Examples of where access to information may be restricted are where disclosure:

  • may pose a serious threat to your physical or mental well-being, or the physical and mental well-being of others;

  • may infringe on the privacy of others; or

  • may hinder law enforcement activities
    

Fees and Cancellation Policy

• Sessions for relationship counselling are for usually for 90 minutes. As progress is made, sessions will shift to less frequent and of 60 minutes.  

• Consultations are available at the Bangalow Professional Centre on Mondays and Wednesdays between 9am and 5pm.  

• Face-to-face consultations are available at the Bangalow Professional Centre on Mondays and Wednesdays between 9am and 5pm.
  

• Cancelled appointments require at least 24 hours' notice or the full appointment fee will be charged as the time has been reserved for your appointment. 

• Further appointments can be made once any outstanding cancellation fees are settled. 

• Medicare rebates cannot be claimed for relationship counselling.  

• You may be able to use private health insurance if you have the appropriate cover.
  

Disclaimer

• While I have taken training in the Gottman Method Couples Therapy, I want you to know that I am completely independent in providing you with clinical services and I alone am fully responsible for those services. The Gottman Institute or its agents have no responsibility for the services I provide.  
  

Provision of a Telehealth Service

• Where appropriate the service may be provided by telephone or videoconferencing. You are responsible for the costs associated with setting up the technology needed so you can access telehealth services.   Terri Kelly will be responsible for the cost of the call to you and the cost associated with the platform used to conduct telehealth services.  
  

• To access telehealth consultations, you will need access to a quiet, private space; and the appropriate device, i.e. smartphone, laptop, iPad, computer, with a camera, microphone and speakers; and a reliable broadband internet connection.  
  

• The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information this practice uses Zoom which is compliant with the Australian standards for online security and encryption

Limitations of a Telehealth Service

• A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the psychology session.

• In addition, there may be some services for which telehealth is not appropriate or effective. Your psychologist will consider and discuss with you the appropriateness of ongoing telehealth sessions. 

Permission for digitally recording and videotaping of therapy sessions

• As a primary tool in Gottman Method Couples Therapy, and in order to augment your therapy work, I use videotape feedback as part of therapy sessions. This means that I may ask to videotape you during specific dialogues or exercises, or during entire sessions. We will play back these tapes in sessions to help you see patterns of behaviour between the two of you and to help you process conflicts. By viewing the videotapes in sessions, it allows us to “stop action” and process how you might approach a conflict in a more productive way. It also allows you to witness your progress as your relationship becomes more satisfying to both of you.
  
  

• In addition to in-session use, I may wish to use the videotapes to receive consultation from Drs. John or Julie Gottman or an independently practicing clinician who has received training from The Gottman Institute, or to provide such training. This may occur during the time of treatment or thereafter for purposes of peer review, education and quality assurance. During this process, your name will be kept confidential. In addition, all matters discussed in consultations will remain completely confidential within the Gottman Institute staff. The videotapes are not part of your clinical record and will be used for no other purpose without your written permission and they will be erased when they are no longer needed for these purposes.
  

• These tapes are my property and will remain solely in my possession during the course of your therapy. Copies may be sent to the Gottman Institute for the purposes noted above. Should you wish to review these tapes for any reason, we will arrange a session to do so. These materials will remain in locked facilities at all times.