Informed Consent Form
Kelly Ranford (M.Ed., MCP, RYT-200) About Me
I look forward to collaborating with you to tackle problems in your life that are bothering you or that are keeping you from being successful in important areas of your life. I am a Registered Clinical Counsellor, R.C.C., registration #14364 with the BC Association of Clinical Counsellors (BCACC). I have a Master of Counselling Psychology, a Master of Educational Practice and a Bachelor of Special Education.
My approach to counselling youth and their families integrates many approaches. Our work together will draw from person-centered, narrative therapy, somatic experiencing, trauma-informed yoga therapy, and EMDR (Eye Movement Desentization and Reprocessing). My training, education, and experience have prepared me to provide treatment for issues of mood disorder, depression, anxiety, anger, trauma, stress, addiction, chronic pain, and family, parenting and relationship concerns. Please feel free to ask me questions about these approaches to ensure that they are a good fit for you and know that at any time I will assist with a referral to a therapist whose practice is more appropriate to serve you.
Things to Consider About Counselling
Counselling may lead to better relationships and finding solutions to specific problems. It may reduce stress and improve your physical health. Counselling may also help you to create a better understanding of yourself and others, increase your coping skills and improve your emotional regulation.
Counselling also involves discussing all aspects of your life. Therefore, you may experience uncomfortable feelings of sadness, guilt, anger, frustration, loneliness, and helplessness. Accessing these feelings may be uncomfortable. Deciding to make changes in belief systems or behavior can disrupt your current lifestyle and relationships. You should consider whether these risks are worth the benefit to you.
If you choose not to enter into counselling, the alternative may be self-help books and videos. The likely consequence of non-action could be the continuation of current circumstances.
Counselling is voluntary. You may withdraw at any time. I recognize that counselling is not beneficial if you are not attending voluntarily. The BC Association of Clinical Counsellors (BCACC) regulate the behavioural norms and standards of professional conduct for Registered Clinical Counsellors. These regulatory bodies have guidelines governing the provision of counselling services and it is your right to make a complaint to the appropriate body should you be dissatisfied with the services received. Please talk to me and let me know if there is something that I can do to resolve any specific concerns. Otherwise contact the BCACC (14 – 2544 Dunlevy Street, Victoria, BC V8R 5Z2. (250)-595-4448).
What to Expect
Sessions will generally be 50 minutes long and we will work together to sort out problems that are bothering you. I will ask you questions, listen to you, and together we will develop a plan to manage these problems. Sometimes you are here because someone in your life has recommended counselling and it is important that you understand that the information you share with me is confidential. There are, however, exceptions to this rule:
- If you give me written consent to disclose certain information
- According to the Child, Family, and Community Service Act, 1995:
“ a person who has reason to believe that a child has been or is likely to be physically harmed, sexually abused, or sexually exploited by a parent or other person, must promptly report the matter to the Ministry for Children and Families.”
- You tell me you plan to cause serious harm or death to yourself, and I believe that you have the intent and ability to carry out this threat in the very near future. I must take steps to inform a parent or guardian of what you have told me and how serious I believe this threat to be. I must make sure that you are protected from harming yourself.
- You tell me you plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future. In this situation, I must inform your parent or guardian, and I must inform the person you intend to harm.
- When so ordered by a court of law. (In this case I will do all that I can within the law to protect your confidentiality and will inform you that this is happening).
If you need to cancel or re-schedule an appointment please contact me promptly so I can schedule others who are in need of an appointment. If there is twenty-four hour notice, there will be no charge. Otherwise, you will be responsible for the full session fee. Your support is appreciated in this area as I have set aside that time specifically for you.
Counselling fees are based on guidelines recommended by the BCACC. I offer a sliding scale fee that can be discussed on a case-by-case basis. Appointments are usually scheduled once a week, or biweekly, or as needed.
The fees are $130 per session. Payment is accepted by cash, cheque, Visa or Mastercard. A receipt will be provided following payment, and may be submitted for reimbursement to an insurance carrier, if applicable.
Your Personal Information
I am required to keep appropriate records of your counselling session. In accordance with the Personal Information Protection Act (PIPA) your records will be maintained in a secure location in the office. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Although they are secured, you, and only you, have access to them. I will sometimes keep records while we are in session and I am willing to share these with you whenever you like. You may also access the records in your file but I request that you initially review them with me, or with another mental health professional as they may be misinterpreted or upsetting. At any time you may request a copy of your file and one will be made available. There will be a fee charged for this service (approximately $50) and this fee is in accordance with the BC Association of Clinical Counsellors.
Contact Outside of Session Time
Any contact of a brief nature for the purpose of modifying or scheduling appointments over the phone between us is included in the routine charges for clinical sessions. I will make every effort to return your call or email of a non-emergency nature within 24 hours during my work week. If this call or email arrives on the weekend or holiday, I will respond on the next workday. For emergencies I will make every effort to return your call within 24 hours and I ask that you call 911 or your family doctor for more immediate care.
Email communication for the purpose of scheduling or modifying appointments may be necessary. Please note that email and/or telephone communication is not secure and privacy cannot be guaranteed.
Signing below indicates that you have reviewed the information above and understand the limits to confidentiality. If you have any questions as we progress through therapy, you can ask me at any time.