Counselling contract | Rebekah Gale | Counsellor

Counselling contract

Please only complete this form after I've confirmed I have availability to see you. Submitting it without my prior request doesn't guarantee an appointment.

First and last name *

Email address *

Phone number *

Date of birth *

Address *

Emergency contact (Name, phone number, relationship to you) *

TERMS AND CONDITIONS

Cancellation Policy

Please let me know as soon as you can if you need to cancel our session.

I reserve the right to charge 50% of our session fee, if you provide less than 24 hours notice. This is because I pay a room hire fee, and do pre-planning admin, before our session.

Payment

An invoice will be sent following our session. Sessions cost $100 unless otherwise arranged with me. Please pay your invoice before our next session.

Consent

As part of providing Counselling services, I will need to collect and record personal information that is relevant to your current situation. This information will be a necessary part of the Counselling for me to provide a relevant service to you. You have the right to withdraw your consent to Counselling at any time.

Purpose of collecting and holding information

Your personal information is gathered as a normal part of Counselling, and it is only viewed by Rebekah Gale. The purpose of this information is to document what is happening during our sessions and enables me to provide relevant and informed Counselling to you. The information I collect is stored securely and cannot be accessed by outside agencies.

Artificial Intelligence

Novonote is used during our sessions to provide dictation and assist with note taking. This is a closed AI service that is password protected. Your name is never disclosed to Novonote and your information is deleted from Novonote after our session.

Confidentiality

All personal information gathered by Rebekah Gale during Counselling wil remain confidential except for:

If I consider you are at imminent risk of hurting yourself, hurting someone else, or you tell me someone else is at risk of being harmed. I can break confidentiality for the purpose of accessing appropriate help for you or the mentioned person in danger. If I do need to gain additional assistance, I will do my best to discuss this with you first.
If your prior approval has been obtained to discuss your information with another professional/agency
If disclosure is mandated by law.
In professional supervision I may discuss information about you for the purpose of gaining insight and ideas into best supporting you. My Supervisor is also bound by confidentiality and will keep what we discuss confidential.

By submitting this form, you are agreeing that you have read, understood and agree to the terms and conditions. If you have any questions or do not understand any of what is written, please discuss this with me either via phone: 020 4011 2352 or via email: rebekahthecounsellor@gmail.com