Welcome to Online Booking for appointments at Parenting Insight Bureau. 

At Parenting Insight Bureau we have compassionate and experienced therapists offering therapy on many issues. Working together with your therapist, you will be able to identify goals for counselling and to evaluate your progress towards these goals.

I also acknowledge that I have been informed here that if my therapist is a Registered Counselor it means they have to obtain supervision at least 1 hour per month with a Registered Psychologist. I further understand that my file information can be shared with their supervisor for the purpose of due diligence and consultation, but that my information will not be released outside of these individuals without my/our written consent.

I understand that should I have a concern with my service or therapist, I can contact Parenting Insight Bureau Clinical Director at 0746515881

INFORMED CONSENT FORM

RELEASE OF INFORMATION AND CONFIDENTIALITY PROCEDURES, PROTECTIONS AND LIMITATIONS

By signing this Agreement, I give my consent for the counselor to be at liberty to request and receive information from myself in the conduct of this assessment. This process will be deemed as open indicating that any information obtained while working with the individuals or family may be used by the assessor in the report that may be provided to both parties or the court through their counsel (if applicable) upon completion of the process.

All information provided will be deemed as on record including all statements or observations during any of the assessment process. This includes all communication directly to or copied to the therapist in any format as well as any information about session attendance, punctuality, behaviors during the sessions attended with the individuals doing the reference.

My personal information will not be used for any purpose other than those outlined in this Consent for Treatment nor be released without my consent except as required and permitted by law. Verbal consent for limited release of information may be necessary in special circumstances which will be discussed and attained prior to any action taken with my personal information. I further understand that there are specific exceptions to this confidentiality which include the following:

A. When there is risk of imminent danger to myself or to another person, the counselor is ethically and legally bound to take necessary steps to prevent such danger. This may include contacting relevant authorities.

B. When there is a reasonable suspicion that a child or elder or any vulnerable person is being sexually, physically or emotionally/psychologically abused or neglected or is at risk of such abuse, the counselor is legally required to take steps to protect the person, and to inform the proper authorities.

C. All other requests for my personal information to be either released or obtained by this counselor or other professionals (e.g., my family physician, lawyers, etc.) will be discussed as they arise and will require my written permission to comply, unless ordered by court.

D). That non-face-to face-work (i.e. phone, video counselling, etc.) has certain confidentiality risks associated with it as Parenting Insight Bureau cannot control the client’s technology access, security provisions, or privacy limitations

I have read and understand the above information and agree to these terms.

This consent form expires upon completion of the intervention unless revoked by me in writing prior to that date.

Signature ------------------------------------------------------------------------------

 Reference Date------------------------------------------------------------

______________________________________________________________________________ Print Name of Reference

Participation in Online and/or Telephone Therapy Sessions

I understand that I have the option to participate in online and/or telephone therapy with my therapist, when and where appropriate to do so. Should I choose to participate in online or telephone therapy sessions, I will do so with following understandings:

Service Limitations and Service Options

I understand and accept the following:

• Parenting Insight Bureau uses the On Call platforms to facilitate secured online therapy sessions.

• For online therapy sessions, my personal information is gathered in coordination with On-Call counselor for the purposes specified in their consent form. My personal information will not be used for any purpose other than those outlined in this Consent for Treatment nor be released without my consent except as required and permitted by law.

• I will read and agree to the terms and conditions specified in On Call’s and Usage Policy prior to proceeding with my online sessions.

• Online and phone therapy sessions are not intended to replace the more optimal in-person sessions, but they are utilized upon my request, when in-person sessions are not convenient or possible.

• There is a potential for misunderstandings when visual cues are absent and/or limited in online communications. As such, either my therapist or I may need to seek clarification when ambiguities or questions of misinterpretations surface.

• Certain therapeutic interventions may not be available through online or telephone means or may have to be modified in order for it to work online or over the phone.

• In order to provide me with the best possible service, my therapist and I will need to routinely review the appropriateness of continuing my therapy online or over the phone, taking my best interest into consideration.

 My therapist or I reserve the right to discontinue my therapy online or over the phone and transfer me to in-person or other means of service should they or I conclude that I would receive greater benefit from in-person services or other means of service. As well, my therapist will, in consultation with me, make a referral for me to another source of mental health care if my therapist is unable to provide adequate or needed services to me.

Technology Limitations

While Parenting Insight Bureau will make every reasonable effort to implement technical security measures to reduce the risk of a confidentiality breach on its end, I recognize and accept the risk that no internet-based communication can be guaranteed to be 100% secure or confidential, and that risks such as internet participation being discovered by others and the possibility of hackers may still occur. I accept that I may be required to provide proof of my identity or other identifiers in order for Parenting Insight Bureau to ensure that my information and service sessions are adequately protected.

 I also understand and accept that technical difficulties or complications may occur at any stage and part of my online therapy sessions. Such may include but not limited to login difficulties, time delays/lags, equipment failure, slow internet speed, and others.

 In the event that any of my online therapy session is disrupted, my therapist will attempt to re-establish our online connection. Should the technical difficulties persist, making it not possible or feasible to continue our online session, my therapist will make efforts to continue our session through other means such as over the telephone or they may have to reschedule another online or phone session for me.

Client Responsibilities for Online Sessions

In order to minimize difficulties or interruptions with your online therapy sessions, you are supposed to observe the following:

• Use high-speed password protected Internet connection or secured, encrypted wi-fi connection. Download and use Google Chrome web browser when and where needed to facilitate your online therapy sessions.

• Use a computer or laptop on which appropriate antivirus/firewall and security software has been installed and activated,

• Ensure that the audio, mic, and visual tools on your computer or laptop are fully functioning,

• Plan ahead to minimize distractions (e.g. use a quiet room that you cannot be uninterrupted, not answering calls or text while in session, use headphones to increase privacy if necessary),

• log-on five minutes early to ensure that the online platform is functioning and that  you are able to complete any pre-session activities such as downloading the platform, read instructions or consent, fill  your  necessary information, etc.,

• Close other programs on your computer prior to the start of your session,

• NOT have any additional individual(s) other than YOUSELF be present in your online therapy sessions without prior approval from the counselor. Should their presence be allowed, you will ensure that they read, understand, and agree to the terms and conditions in this Consent for Treatment, and

• NOT record (audio, video, or any other form) or share any portion of your online therapy session(s) with any party without prior written approval from Parenting Insight Bureau.

Attendance and Cancellation

If you are booking a family or couples session, please ensure the names of all people attending the session is included in the booking. If you are booking in for child counselling, please book the appointment with the child’s name, if the appointment is not booked under the child’s name and we do not have proper consent on file, we may have to cancel the appointment

Individual therapy sessions are between 50 and 55 minutes in duration. Session frequency can vary over the treatment period, depending on the specific therapy goal and the progression of treatment. I agree to inform Parenting Insight Bureau at least 24 hours prior to our appointment time if I need to cancel or change an appointment time. I understand that unexcused no shows or cancellations with less than 24-hour notice will be automatically billed/charged at 50% of the total cost of the session booked.

Financial Agreement

I understand and accept that am supposed to have fully paid for the session unless stated otherwise, for a face-to-face, online, and telephone therapy/consultation session. Such a session entails 50 to 55 minutes of meeting time and 5 to 10 minutes of report writing time and this excludes initial telephone, in-take, or scheduling time).

 I also understand and accept that other billable services, such as report writing, professional letters, form completion, and review of written records from other specialists are billed at the same rate unless made known to me otherwise. I understand that a retainer amount may be collected to hold an appointment or prepare for an assessment and that additional charges will be added to that retainer to reach previously discussed or agreed upon fee for service and fees shall not exceed the agreed upon amount.

For in-person therapy sessions I agree to pay promptly at the time of check-in for each session, all fees and charges owed to Parenting Insight Bureau, except for the amounts that can be immediately received or that have already been approved for payment by a third party through instant direct billing to Parenting Insight Bureau or through a pre-established contractual agreement.

 Parenting Insight Bureau accepts M-Pesa or payment though it Bank account to be provided for the in-person therapy sessions to be rendered.

For online or telephone therapy sessions I agree to pay 48 hours prior to each session, all fees and charges owed to Parenting Insight Bureau except for the amounts that can be immediately received or that have already been approved for payment by a third party through instant direct billing by Parenting Insight Bureau or through a pre-established contractual agreement.

Should my payment be rejected/declined at the time of processing, Parenting Insight Bureau will contact me by phone, text, and/or by e-mail to notify me of this payment failure and to provide me with an opportunity to rectify the matter.

I understand and fully accept that should Parenting Insight Bureau not receive full payment from me at least 24 hours prior to my online, telephone, my session will be automatically be cancelled and the Bureau will send me an e-mail notice of cancellation.

By choosing to proceed with my online and/or phone therapy session, I acknowledge that I have read, understand, and agree to all the terms and conditions specified in this Consent for Treatment.

With my signature below, I acknowledge that I have read, understand, and agree to all the terms and conditions specified in this Consent for Treatment.

Client’s Name (print): _______________________________________

Signature: ________________________________________

Date: ______________________________________________

E-mail: ____________________________________________

 Phone Number: ___________________________________