CONFIDENTIALITY

By signing this form, I consent that Kalina Bains may release information to a specific individual or agency if it has been determined that a vulnerable person (child or elder) is at risk; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested.

 

I also understand that, at any time, Kalina Bains may discuss aspects of my case with other colleagues, keeping my full name and identity completely confidential always unless I have given permission otherwise.

 

 

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I _________________________________ agree to the above information from Kalina Bains. 

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SIGNATURE

Please sign this form and send it back BEFORE your session.

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Full Name:  

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Signature: 

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Date:

 

 

MEDICAL OR PSYCHOLOGICAL CONDITIONS

I may ask questions about your medical history to establish any contra-indications to our sessions. This will also help to assess whether your health is affecting (or being affected by) the sessions goals you wish to achieve. Please update me of any medical changes during your sessions, or if you are returning to your sessions after a period of absence.

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If you are receiving care or treatment from any medical, healthcare or therapy practitioner, e.g. Counsellor, GP, Psychologist, or Psychiatrist you may be asked to seek their permission before any sessions can commence.

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Kalina Bains

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