Confidentiality & Cancellation Policy — Moose Anger Management

Telehealth Informed Consent

Here is an outline of expectations for attending our online and phone sessions. When you submit this document, it will represent an agreement between us. Please let me know if you have any questions.*

I will ensure that no one is within hearing or visual range of me or my electronic device during the session. This is especially true for family members or friends.
It is important to have a secure internet connection rather than public or free Wi-Fi, which will not provide confidentiality.
We will ensure that we use encrypted platforms, however, even though it is very unlikely, there is a limited risk that unauthorized people could access our private conversation.
It is critical that the emergency contact person information is completed, in the event of a crisis situation. Please complete this in our Confidentiality Policy.
Recording of sessions is not permitted without the express permission of everybody involved. Group sessions may be recorded for supervision purposes only.
If the internet connection drops, the counsellor will contact you via text/phone or email to discuss how to complete the session.
If the internet fails and you are in an emergency call 911 or a crisis centre or go to the closest emergency services. Call back the counsellor after calling emergency services.

Confidentiality Policy

All conversations are private unless:

On-going child abuse is discussed
A threat to a person’s life is clearly implied (your own life or another’s)
An indictable offense (armed robbery for instance) that was completed recently or planned is discussed
I am subpoenaed by the courts

Outside of these four points all conversations will stay private.

If a person’s employer is paying for these sessions, the employer will be notified of a no show, or if the person does not engage in the program.

No Show/Cancellation Policy

If you know that you will miss a session prior to the start of the group, we can organize that you attend that session in another group at no cost. You can also complete the missed session with one of our counsellors individually for an extra fee. If you don’t let us know that you will miss a session, there is a $75 drop-in fee. As a graduate, after taking the six - week program you can also attend any one session for $75 for a tune-up.

Client Name*

First Last

Client Phone*

Client Email*

Address from where you will be attending the meetings

Confirmation*

I have read and agree to the confidentiality and cancellation policies.

Emergency Contact

Emergency Contact Name*

First Last

Emergency Contact Phone*

Relationship to Client*

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