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SECTION A: CLIENT INFORMED CONSENT & SERVICES AGREEMENT
This section provides information on the policies and practice of counselling & psychotherapy at
ARK COUNSELLING & CONSULTATION (“ARKCC”)
It is intended to help you make an informed decision about whether you would like to accept the service. If you have any questions or concerns while you read this form, please do not hesitate to ask and discuss with us. Do not sign the form until all of your questions and concerns have been addressed.
COUNSELLING is a confidential process designed to help you address your concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a trained counsellor and/or clinical psychologist (collectively referred to as "Therapist") who has the desire and willingness to help you accomplish your individual goals. Counselling involves sharing sensitive, personal, and private information that may at times be distressing. During the course of counselling, there may be periods of increased anxiety or confusion. The outcome of counselling is often positive; however, the level of satisfaction for any individual is not predictable. Your therapist is available to support you throughout the counselling process.
PRIVACY & CONFIDENTIALITY
The personal information on this form is collected and needed by our therapist in order to provide the best and most appropriate counselling services to our clients. All information shared with the therapist is private and confidential, including scheduling of or attendance at appointments, content of your sessions, progress in counselling, and your records are confidential. Your information will not be released to others without your signed permission, and you may request in writing to your therapist to release specific information about your counselling to persons you designate. However, please note that any communication through email, text or telephone is not secure and privacy cannot be guaranteed. Therapist work to the Kod Etika Kaunselor of the Lembaga Kaunselor Malaysia, or the Allied Health Professions Act, 2016 (Act 774), where applicable. Therapists keep notes, and also see a professional supervisor, for which they may use their notes. They do not use your full name or say anything which identifies you. The Service receptionist and staffs may see this Registration Form, but not see your therapist’s notes. This Registration Form, Counselling notes and a summary of the counselling progress, will be kept for up to 7 years starting from the service last provided. All records and forms are kept securely and separately.
A therapist would consider breaking confidentiality only in very exceptional circumstances, where you or someone else could be at risk of serious harm, or where required by law:
EXCEPTIONS TO CONFIDENTIALITY:
If there is evidence of clear and imminent danger of harm to self and/or others, a therapist is legally required to report this information to the authorities responsible for ensuring safety.
When a minor (any person under 18 years of age) is involved, child abuse may be occurring.
A court order, issued by a judge, may require a therapist to release information contained in records and/or require a therapist to testify in a court hearing.
The counselling staff works as a team. Your therapist may consult with other counselling staff to provide the best possible care. These consultations are for professional and training purposes.
Counselling sessions are typically 60 minutes in length per session for individual or 90 minutes in length per session for couple/group, at a rate agreed upfront. Payment shall be made before the session start. The number of sessions required is individual to each client and is dependent on the nature and complexity of the client’s concerns, the strength of the relationship between the client and therapist, and the commitment to work on the presenting issues.
CANCELLATION & NO-SHOW POLICY
Once your appointment is confirmed, a minimum 24 hours’ notice is required for reschedule and/or cancellation; otherwise, the full session fee will be charged and payable by you at the beginning of the following scheduling. If you do not show up for your appointment, full session fee will be charged and payable by you at the beginning of the following scheduling.
ROLE OF THE THERAPIST
The relationship you have with your therapist is different than other relationships. While you will be sharing personal details with your therapist, you will know little about them. Some clients find this difficult, but please keep in mind that your therapist is part of the professional association that has rules about the types of interactions they are allowed to have with clients. As part of these rules, your therapist:
Cannot have any kind of romantic, friendship, or sexual relationship with a current or former client or any people close to a client
Cannot give or receive gifts from clients
Cannot accept invitations to or attend personal events of clients
Cannot have any other kind of business relationship with you besides counselling itself
Keeping in mind privacy and the confidential nature of counselling, your therapist will not approach or acknowledge you in the community unless you initiate contact. This is not meant to be rude, but rather to protect your privacy.
RIGHTS OF THE CLIENT
As a client, it is important to remember that you have several rights that you are free to exercise:
To be treated with respect and dignity
To refuse particular counselling interventions
To withdraw this consent at any time
If at any time you do not feel as though your rights are being respected, please do not hesitate to address your concerns with your therapist or our staff.
SECTION B1: CLIENT INFORMATION
SECTION B2: EMERGENCY CONTACT
SECTION B3: MENTAL HEALTH HISTORY
SECTION C: PREFERENCE FOR SESSION
# For Couple/ Marriage Session, both partner need to register separately.
## For Family / Group Session Only: Kindly provide the details of other client(s) at below:
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