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Consent Form

Prior to your first appointment, please complete the following Confidentiality and Consent Form.

The information will be submitted electronically using encryption and will remain confidential, and not be shared with anyone without your written consent.

Abma Counselling Services 

Confidentiality and Consent Form

Please complete this confidentiality and consent form prior to your first appointment.

Parents or guardians: Complete this form for clients under the age of 16.

Purpose and Nature of Counselling

When people engage in counselling, they are often ready for change in some aspect of their life. Counselling can lead to improved mental health by helping you better understand your thoughts, emotions and behaviours. It can also improve your relationships, how you relate to others, and the world. The number of counselling sessions you have depends on the goals you set and how long it takes to reach these goals. Your counsellor will work collaboratively with you to help you set and achieve your goals while facilitating personal growth through the counselling process.

Collection and Storage of Personal Information

We maintain records on the content of our sessions, which are locked in a secure location, and can only be accessed by Abma Counselling Services. This is done in accordance with CRPO and OCSWSSW guidelines and the Personal Health Information Protection Act (PHIPA). 

Fees

A standard 50-minute counselling session costs $115 - $120. We also have sliding fee options available for clients in need. If finances are a concern for you, please discuss this with your therapist.

Payment can be made at the end of each session using Visa, or MasterCard. The credit card used at the time of booking is only for the purposes of securing your appointment, and to cover the cost of missed appointments or late cancellations. Your therapist will collect a card number from you and use this card to process payment for each subsequent sessions. A receipt will be provided for your to use when claiming benefits through an employee health plan or a non-insured medical expense on your income taxes.

If you wish to change or cancel an appointment, please provide 24 hours notice via email or phone. If you miss your appointment or do not provide 24 hours notice, you will be charged the full amount of the session.

Confidentiality

All information you share with us is strictly confidential and will not be released without your voluntary and written consent. As part of routine practice, we may, on occasion, consult a clinical supervisor on your case in order to provide you with the best care. Your confidentiality will be strictly maintained and your name will not be used. There are limitations to the confidentiality described above and these include:
– Reporting of suspected child abuse or neglect
– Complying with the requirements of a child protection investigation
– Complying with a subpoena
– Responding to a threat of harm to self or others

If it appears that you are imminently about to harm yourself or someone else, we are ethically and legally obligated to let someone know. More important than the legal obligations, though, are our concerns for your health and safety, and that of those with whom you interact.

FOR ONLINE APPOINTMENTS: Online communication is not 100% secure. There are risks involved and it is important that you are aware we cannot guarantee your protection. Common videoconferencing services, such as Skype, are not secure and data is stored in web servers and thus subject to electronic monitoring. We use our own software to increase security, however it is important that you secure your privacy as much as possible. All of our counsellors’ information is secured according to HIPAA policy regulation. If a breach occurs, we will remedy it as soon as it is discovered by taking the necessary steps to recover your personal information, secure remaining information and notify all parties involved immediately. If these risks are of concern to you, in-person or telephone counselling are alternative ways to connect with one of our counsellors.

Please indicate below that you are giving your consent to receive our counselling services.

Client / Guardian Signature

Client / Guardian Signature

Abma Counselling Services has been providing counselling services in Niagara since 2008. What began as a solo practice by Steve Abma has grown into a group practice of eight experienced therapists providing treatment for a wide variety of issues, including depression, anxiety, ADD, relationships, marriage, addictions & stress. We are a team of dedicated professionals, passionate about helping individuals, couples and families feel and be their best.  Serving Niagara Falls, St. Catharines, St. David's, Niagara-on-the-Lake, Virgil, Fort Erie, Ridgeway, Beamsville, Jordan, Vineland, Grimsby, Thorold and Welland.

​© Steve Abma. Published by Steve Abma.