Call me:    07866 502566

Hilarie Janes - Psychotherapy That Works Human Givens Psychotherapist HG Dip P MHGI                email

 

Call me for an appointment on:  07866 502566


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All Clients will be required to complete a Consent Form, such as the one below.


Client Consent and Confidentiality Agreement

I have been informed that all private consultations adhere to the ethical guidelines regarding confidentiality and Therapist professionalism, as laid down by the Human Givens Institute. I also understand that confidentiality may only be broken in the following circumstances:

                    Those relating to the harm of others

                    Those relating to the harm of self i.e.if you are likely to self harm

                    In the identifying of risk(s) to children or vulnerable adults

                    In any suspected acts of terrorism or potential danger to others

                    In circumstances relating to my vital interests.

                    For any legitimate legal purpose / subpoena.

(If for any reason my Therapist feels that confidentiality must be broken, they will wherever possible, discuss this with me prior to any action being taken.)

I agree to abide by the following Therapy Consent:

  1. -To attend on time in person or by telephone/internet link as arranged with my Therapist for appointments.

  2. - To be fit to engage in therapy by not being intoxicated or affected by drugs/medication for all individual face to face or group sessions. I understand that I will be asked to leave if I am not fit for my therapy session and that payment will be due in full for the cost of the session.

  3. -To cancel any planned appointments with a full 24 hours notice. Should this not be given the full charge for the session will be payable. Cancellations with more than 24 hours notice will not be charged.

  4. -If I fail to attend for a pre-booked phone or face to face session and there is no 24 hour cancellation, then a full charge will be made for the session and no refunds made for any payments made in advance.

I understand that in order to maintain the highest standards, it is a condition of their Profession that Therapists must receive formal and professional supervision from a qualified member of their Institute. Under these circumstances individual cases may be discussed under the strictest confidence. No personal details will be released except under the circumstances relating to confidentiality - as listed above.

I understand that therapy will be completed following discussion with my Therapist, and by mutual consent, although I reserve the right to cancel this agreement with 24 hours notice being given, and following discussion with my Therapist.

Block Capitals Please.

Client Name: ................................................  Date of Birth:.........................

Client Address: .........................................................................................

............................................................................................................

Client contact number: ......................................

Client Signature: ..............................................

Date: .......................................  Therapist name: .......................................


About the Human Givens Institute: http://www.hgi.org.uk/institute.htm

Human Givens Ethical Guidelines: http://www.hgi.org.uk/ethicspolicy.htm




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Hilarie is a Human Givens Psychotherapist and Counsellor practising in Marlow Buckinghamshire.  She is experienced in the use of hypnosis, hypnotherapy, and many other therapeutic and life coaching techniques.

Call her on:   07866 502566



Copyright  Hilarie Janes 2011