Consent for Service combined form

FACE TIME

3. FaceTime is an online communication tool allowing face-to-face video, voice, or text-based chat/dialogue. FaceTime-to-FaceTime calling is encrypted to protect sensitive information. For more information on how FaceTime keeps its client’s information private, please visit and review the information at the following link http://www.apple.com/business/docs/iOS_Security_Guide.pdf
4. FaceTime software is available on any iOS device.
5. Any Internet-based communication is not 100% guaranteed to be secure/confidential.
6. I have read the privacy and encryption information for Apple FaceTime and I agree that Dr. Lorri Yasenik nor Lorri Yasenik Counselling, and Consulting Ltd should not be held responsible if any outside party gains access to FaceTime account information or transaction by bypassing online security measures.

ZOOM MEETINGS

7. Zoom is an online communication tool allowing face-to-face video, voice, or text-based chat/dialogue. Zoom to Zoom conference call sessions can occur from PCs, Macs, Tablets and telephones. Conference calls are encrypted to protect sensitive information. For more information on how Zoom keeps its client’s information private, please visit and review the information at the following link  https://zoom.us/docs/doc/Zoom-Security-White-Paper.pdf
8. Any Internet-based communication is not 100% guaranteed to be secure/confidential.
9. I have read the privacy and encryption information for Zoom Meetings and I agree that Dr. Lorri Yasenik nor Lorri Yasenik Counselling, and Consulting Ltd should not be held responsible if any outside party gains access to the Zoom account information or transaction by bypassing online security measures.

SKYPE

Skype is an online communication tool allowing face-to-face video, voice, or text-based chat/dialogue. Skype to Skype conference call sessions can occur from PCs, Macs, Tablets and telephones. Skype calls are encrypted to protect sensitive information. For more information on how Skype keeps its client’s information private, please visit and review the information at the following link  https://docs.microsoft.com/en-us/skypeforbusiness/plan-your-deployment/security/key-security

10. Any Internet-based communication is not 100% guaranteed to be secure/confidential.
11. I have read the privacy and encryption information for Skype Meetings and I agree that Dr. Lorri Yasenik nor Lorri Yasenik Counselling, and Consulting Ltd should not be held responsible if any outside party gains access to the Zoom account information or transaction by bypassing online security measures.

Responsibilities as Adult Client (Online):

Maintaining Confidentiality and Safety

1. I agree I will not for any reason make a recording of the online session provided. I agree that it is an offence to make any unauthorised recording of the session (in any format) without the express permission of all involved.  I understand that any recorded materials will be inadmissible in any court, assessment, arbitration, or other legal processes.
2. I am responsible for ensuring confidentiality by:

   - Being in a private space in my home, workplace or other suitable location. Headphones may be used to increase privacy of session.

- Ensuring that other programs and private information on my computer and desk is not within view during the session.

3. I will ensure that children and others cannot hear the conversations, or see information provided on the screen during the meeting.
4. I understand that I need to ensure that my digital technology meets the current safety requirements for the purpose of undertaking an online meeting. I will undertake to review e-safety requirements such as those described at: https://www.getcybersafe.gc.ca/index-en.aspx
5. I agree that I will call 911 in any emergency or go to the nearest Emergency Room. I will not use the online meeting platform in a critical situation.
6. I understand that for my safety I will provide Lorri Yasenik with my physical address at which I am regularly living AND the address at which the online meeting is occurring. I understand that Lorri Yasenik will retain my residential address on file and will only make use of the meeting address if she forms a concern for my safety or the safety of others.

ENTERING THE ONLINE MEETING

7. I am responsible to plan ahead to minimize distractions, and not answering calls or text messages while in the meeting.
8. I agree to be online five minutes prior to the scheduled e-session appointment.
9. I agree to avoid the use of drugs and alcohol before or during the online meeting.

Responsibilities of Dr. Yasenik and Lorri Yasenik Counselling and Consultation Ltd:

MAINTAINING CONFIDENTIALITY AND SAFETY

1. Every reasonable effort has been made to implement technical security measures that reduce risks of a confidentiality breach.
2. Yasenik will ensure she is alone with a secure high quality, password protected wireless Internet connection.

ENTERING THE ONLINE MEETING

3. Yasenik will:
   - Issue an invitation to the online meeting via email or such other media suitable for the meeting to occur. Invitations will be made as soon as practicable upon request or offer of an online meeting.
   - Enter the online meeting approximately 5 minutes prior to the agreed time for the meeting
   -Ensure that distractions such as phone calls and text messages are silenced during the video counselling session.
4. All meetings will be scheduled in Mountain Standard Time.

TECHNICAL DIFFICULTIES

5. Technical problems may occur. If a call is disrupted, Dr. Yasenik will call back unless technical difficulties persist. In such cases, the session can be continued via phone or rescheduled via phone or email, depending on client’s preferences.
6. If technical problems persist and the client does not want to continue the session the session fee will be pro-rated for elapsed time.

PAYMENT

7. Lorri Yasenik will process the payment for the session utilising the Credit Card information provided by the client(s) as per the original service agreement. Payment is due upon conclusion of the meeting or within a reasonable time of the meeting conclusion.

Parent/Caregiver Responsibility

As the parent caregiver:

1. You will need to assist your child until he/she is on-line, and the connection is clear
2. You will need to be available in case the connection is interrupted, and your child needs you to help to trouble-shoot a lost connection
3. You will ensure your child has privacy, which includes ensuring he/she has privacy from others in the household for example others do not know about your child attending therapy
4. You will ensure your child has sound privacy in the space. White noise outside of the room is helpful. Many children have sound machines to help them sleep which could be situated outside the door
5. You will ensure no one will come into the child’s space during the session time
6. You will help the child make a “Private Folder” for art products. This can be two pieces of cardboard stock stapled all the way around leaving the top open to make a big envelope (or a special bag in which to keep products)
7. Parents agree to not question their children about their on-line sessions, or ask the child to discuss any product completed during the session
8. You may be asked to be on-line in a separate space called “a break-out room” so that you can be available as necessary

Tele-Play Therapist/ Distance Practitioner Responsibility

Dr. Yasenik as the Tele-Play Therapist/Distance Practitioner will:

1. Send the invitation to the parent to set up the session
2. Adhere to any privacy issues re: family home as the therapist will be in one or more rooms of the family’s choice
3. Engage in a check-in with parent and child together prior to beginning the private session 5-10 minutes. Together we will address confidentiality – children will be given permission to tell their parents that their time is private (but not secret)
4. Plan and manage the session with the child for 30-45 minutes
5. If the child has an iPad, the Tele-Play Therapist may ask the child to do a 360 degree turn of the room from time to time to ensure privacy for the child and the therapy process
6. Help the child end the session and put any products away into their private folder/bag
7. Send the parent a brief email note after the session has been completed. The email will provide the parent with short summary as to how the session generally went and if the child was engaged. As per the original Consent for Treatment Agreement, there will be no formal reports provided after Tele-Play Therapy sessions unless identified/outlined in the initial Consent for Treatment Agreement.

For children of Separation and Divorce who are involved in a child inclusive process, feedback to parents and third parties may occur in one of the following ways:

• A Structured Feedback Session with both parents (either together or individually)
• A formal Report that is provided to the Court (Voice of the Chid Report)
• A written report as requested by an Arbitrator
• Oral report provided to an Arbitrator

Benefits and Risks to Tele-Services

One of the benefits of tele-services is that the client and practitioner can engage in services without being in the same physical location thereby ensuring continuity of care. Tele-services do, however, require technical competencies to be helpful.  Although there are benefits of tele-services there are some differences between in-person and distance interventions.

Teletherapy services rely on technology, which allows for greater convenience in service delivery. Any internet-based communication is not 100% guaranteed to be secure/confidential. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties.

Risks to confidentiality. Because tele-sessions or meetings take place outside of the practitioner’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. The practitioner will take reasonable steps to ensure your privacy. It is important you also ensure you find a private place for the session where you will not be interrupted.

Tele-sessions are not meant to take the place of the more optimal in-office face-to-face sessions but are utilized when in-office sessions are not convenient or possible, and only at the client’s request. Most research shows that tele-sessions are about as effective as in-person sessions. However, some practitioners believe that some non-verbal cues can be lost by not being in the same room.

If the practitioner decides that tele-services are no longer the most appropriate form of treatment/interventions she will discuss options of engaging in in-person counselling or referrals to another professional who can provide appropriate services.