Confidentiality & Cancellation Policy — Moose Anger Management

Telehealth Informed Consent

Here is an outline of expectations for attending our online group 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 (Zoom). While this significantly reduces risks, it is important to note that there remains a small possibility of unauthorized access.
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 by the counsellor for supervision purposes only, and participants will be informed in advance.

Technology and Emergencies*

If the connection drops, the counsellor will attempt to reconnect or contact you by text, phone, or email to continue the session.
If you are in an emergency, call 911 or a crisis centre first, then notify the counsellor afterward.

Confidentiality Policy

All conversations are private unless one of the following circumstances arises:

Ongoing child abuse is disclosed
A threat to a person’s life is clearly implied (your own life or another’s)
An indictable offense (e.g., armed robbery) that was recently completed or is being planned is disclosed
The therapist is subpoenaed by a court of law and legally required to release records or provide testimony

Outside of these four circumstances, all conversations will remain confidential.

Group-specific confidentiality: Each participant agrees to respect the privacy of others by not sharing names, stories, or details outside the group. While the counsellor commits to confidentiality, it cannot be guaranteed that all participants will uphold it.

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 before the start of the group, we can organize for you to 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 drop-in fee. As a graduate, after taking the six-week program, you can also attend any one session for a tune-up for a drop-in fee.

Client Name*

First Last

Client Phone*

Client Email*

Address from where you will be attending the meetings

Address (from where you will be attending the meetings)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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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