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Counselling Online Consent Form

Thank you for using University of Regina Counselling Services.
We are here to help you. By completing this form, you will assist us in meeting your counselling needs at this time.

Date* UR Student ID*
First name* Last name*
Address* Postal Code*
Email*
Age* Gender*
Relationship Status* Number of Children*
Faculty and Program of Study*
Registered through*
U of R Campion College Luther College First Nations University
Have you seen a clinician at Counselling Services before? Yes, year(s) No
Are you currently, or have you in the past accessed other mental health counselling services?
Yes, year(s) No
Have you had a Time Limited Consult (TLC) session?
Yes, year(s) No
For us to be most helpful, is there anything you feel is important for us to know about your culture, ethnicity, religion, language, sexual orientation, gender identity/expression, mental or physical health, or other?
We provide in-person as well as virtual services (E-Counselling).

What is E-Counselling?

E-Counselling (also known as E-Therapy, Telehealth, Telepsychology or Teletherapy) is technology assisted counselling. It is provided in “real time” with livestream audiovisual format and secure internet technology. The purpose of E-Counselling is the same as that of psychological treatment provided in person. However, due to the use of the technology, E-Counselling may be experienced somewhat differently than if you were receiving face-to-face services in person. E-Counselling is also a collaborative process between you, the client, and your clinician that involves the provision of education about your mental health concerns, as well as the use of therapeutic strategies and interventions.

E-Counselling will involve arranging a mutually agreed upon appointment time when both you and your clinician can meet via the internet. It can also involve the exchange of written information through password protected electronic means (in conjunction with the livestream sessions). The clinician providing E-Counselling to you will be on campus, in a Counselling Services office at the time. Your clinician will be available for E-Counselling only during regular office hours (8:30 am to 4:30 pm).

Client Requirements

In order to qualify for E-Counselling services, you must be a registered student and physically located in Saskatchewan. E-Counselling is not available to students located in another province or country.

To access E-Counselling you must first attend a Time Limited Consult(TLC) session. The purpose of requiring this is for validation of identity, screening for suitability for E-Counselling services, and orientation to the process of E-Counselling. Certain mental health issues including acute and chronic crises, recent psychiatric hospitalization, psychosis, substance abuse, and moderate to severe mood and eating disorders are not appropriate to be addressed via E-Counselling services. Treatment of risk of harm to self or others is also not appropriate to be provided via E-Counselling services. If this is the case in your situation, or becomes the case in the future while you are receiving E-Counselling, more appropriate services will be recommended.

Technology Requirements

To access E-Counselling you will need a computer with internet access and a webcam. You will also need access to a telephone during sessions. Our E-Counselling Service Provider is Zoom. Instructions for setting up your Zoom link with your clinician will be provided to you via email. The Zoom privacy policy is available at https://zoom.us/healthcare.

Counselling is a collaborative process between you, as the client, and your clinician. The process involves the provision of education about your mental health concerns, as well as the use of present focussed and change oriented therapeutic strategies and interventions. As such, there are very important details regarding the therapeutic process that you should be aware of at the onset of counselling:

  1. I have the right to withdraw consent for counselling services at any time and it will not jeopardize my access to future counselling services.
  2. If E-Counselling is not appropriate for my situation, I will be provided with alternatives, including resources and/or contact information for in-person mental health treatment providers in my area. I understand that an opening with the providers in my area may not be immediately available.
  3. I understand that there are potential risks and benefits associated with receiving counselling. The benefit and goal of counselling is to receive support and develop skills to better manage my concerns. However, despite my efforts and the efforts of my clinician, my symptoms or situation may not improve, and in some cases may even get worse.
  4. I understand that I may benefit from E-Counselling, but that results cannot be guaranteed or assured. My clinician and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of this technology. I will provide feedback to my clinician should I find that this delivery format is not meeting my needs.
  5. I know that despite all reasonable technology security efforts, there remains a risk that the transmission and communication of my E-Counselling sessions may be breached and accessed by unauthorized persons.
  6. For E-Counselling it is my responsibility to maintain privacy on the client end of the transmission and communication. I will take precautions such as using a private space, a secure and reliable internet connection, a headset, and muting in the event of an unexpected interruption. It is the responsibility of the clinician to do the same at their end.
  7. The federal and provincial privacy laws (e.g. the Saskatchewan Health Information Protection Act), and the professional ethical standards of my clinician that protect the confidentiality of my health information, apply to in-person counselling as well as E-Counselling. As such, I understand that the information disclosed by me during the course of my sessions (and over the telephone, by mail, or via email) will in general be kept confidential, and will be used to provide me with counselling and related services. I understand that my personal health information will not be released without my written consent unless required as noted below in the exceptions to confidentiality. Unless the situation is an emergency, consent must be provided in writing (signature required) and cannot be provided over the telephone or via email.
  8. I also understand that there are exceptions to the confidentiality obligations and privacy rights described above. These include, but are not limited to, reporting suspected neglect of, and harm to a child; addressing imminent risk of serious harm to self or others; providing information in response to a subpoena or court order; providing information required by legislation (e.g. SGI or WCB); and as otherwise permitted under The Local Authority Freedom of Information and Protection of Privacy Act.
  9. My client file will be maintained electronically on a secure server with Information Services of the University of Regina. Only my clinician and my clinician’s immediate supervisor will have access to my client file. The information will be maintained for 7 years following the date of the last counselling services provided to me, as required by legislation. I understand that I have a right to access my client file information during or after services have ended.
  10. I may see a clinician that is a counselling assistant (doctoral student) or a provisionally licensed psychologist. The clinician will inform me of their status and identify their clinical supervisor.
  11. I can be contacted during office hours and messages from my clinician can be left:
    Telephone
    Email
  12. There is a risk that E-Counselling services could be disrupted or distorted by unforeseen technical problems. In the event of disruption of service, I will be contacted by telephone by my clinician as soon as possible after the disruption occurred. I can be reached at:
    Telephone
  13. In the event of crisis concerns, my emergency contact is:
    Name
    Relation
    Telephone
  14. I agree that if I find myself in a life threatening or emergency situation, I will immediately call 9-1-1. If I require crisis oriented mental health care services I will contact my local or nearest primary health care facility.
    I, hereby acknowledge that I have read, understand and have accepted all the above statements relevant to receiving counselling with Counselling Services of the University of Regina.
    Student Number