John Day - Psychologist
ONLINE THERAPY CONSENT FORM

Online Therapy is a counselling service provided via technology.

I also understand that online therapy involves the communication of my mental health information, both orally and/or visually. Online therapy has the same purpose or intention as face to face counselling sessions.

However, due to the nature of the technology used, I understand that online therapy may be experienced somewhat differently than face to face sessions.

I understand that payment for online therapy is required via eft to the bank details after each session. I understand that I have the following rights with respect to online therapy.
Client’s Rights, Risks and Responsibilities.
1. I, the client, have the right to withhold or withdraw consent at any time.

2. The psychologist will protect the confidentiality of information as with face to face counselling. As such, I understand that the information disclosed by me during the course of counselling is confidential. However, there are both mandatory and permissive exceptions to confidentiality, which your psychologist must legally adhere to.

3. I understand that there are risks and consequences of participating in online therapy, including, but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of my psychologist, that; the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorised persons; and/or electronic storage of my information could be accessed by unauthorised persons. There is also a risk that services could be disrupted or distorted by unforeseen technical problems.

4. In addition, I understand that online therapy based services and care many not be as complete as face to face services.

5. I accept that my psychologist does not provide emergency services. If I am experiencing an emergency situation, I understand that I can proceed to the nearest hospital emergency room for help. I can also seek the assistance of twenty-four-hour emergency assistance (for example; Life Line or the suicide Hot line), in need. If this is the case, or becomes the case in the future, my psychologist will recommend more appropriate services.

6. I understand that there is a risk of being overheard by anyone near me if I am not in a private space while participating in online therapy. I am responsible for

a) Providing the necessary computer, cell phone, telecommunications equipment and internet access for my tele-counselling sessions; and

b) Arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my session. (Your psychologist will ensure the same on their end).

c) I will ensure that the online therapy session is not recorded by me in any form.
Name & Surname *
Email *
Contact Number *
Emergency Contact Name & Surname *
Emergency Contact *
I have read, understood and agree to the information provided above regarding online counselling. *
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