The Compass Rose Health and Wellness Centre 

36 Brookshire Court, Suite 200

Bedford, Nova Scotia, B4A 4E9

(902) 346-2158

www.thecompassrose.ca

Life Happens...and we can help!

Child & adolescent Consent Form

Statement of Understanding

~Sessions with a Child and Youth Counsellor/Worker are confidential. This means I (the CYCW) will not reveal that you (the child/adolescent client) have been receiving counselling from a CYCW, or the content of what we have discussed apart from in the following situations:

▫️​When disclosure is required to prevent clear and imminent danger to the client or others (When client discloses they want to harm them self or others)

▫️When legal requirements demand that confidential material be revealed (When there is a court order)

▫️When a child is in need of protection (When I have knowledge that any harm or abuse has or could occur to a child or vulnerable adult)

• NOTE: You (the child/adolescent client) are at liberty to share any of your own personal information concerning our sessions that you desire, to whomever you choose.

~Our first session will be a brief opportunity to discuss the issues that will be the main focus of our therapeutic relationship, to set in motion the foundation for relationship building and to provide both you (the child/adolescent client) and your parent(s)/guardian(s) an opportunity to ask questions about the treatment process.

​​▫️At any point during this process, you are encouraged to make adjustments by adding or changing what issues you choose to discuss in our sessions

​​▫️Treatment planning will always remain a collective effort between you, your parent(s)/guardian(s) and myself (Jen Carter – CYCW)

​​ ▫️On occasion, our treatment plan may possibly include a referral to other health care professionals and/or community resources in addition to my services.

~Personal health information necessary to the provision of services is collected, stored, released, and used under the provisions of:

▫️PIPEDA – The Personal Information Privacy and Electronic Documents Act of Canada and

▫️PHIA- The Nova Scotia Personal Health Information Act

▫️This document serves as notice that this information is being collected and that you have various rights and responsibilities under these acts to ascertain what information is/will be collected and how it will be used, transmitted, or stored.

▫️You will be informed of any unintended release of your health information, however caused, at the first opportunity available to the health professional.

~24 hour notice is mandatory for cancellation of an appointment other than for personal illness or family emergency.

▫️Failure to provide adequate notice may result in being charged for the full session.

▫️In any event, notice of session cancellation, however late, may allow for the rebooking of a session in favour of another client, in which case no session cancellation fees would apply.

▫️Therefore, it is always in the client’s best interest to communicate at the earliest possible time when a session must be missed.

~Payment​

▫️Will be made at the close of each session or as agreed to between The Compass Rose Health and Wellness Centre and client and/or the organization responsible for payment on a third party basis.

▫️Payments are the responsibility of the client even if some or all of a session fee may be covered by third parties.

▫️Sales tax HST of 15% will be collected above and beyond the billed cost of services.

~Consent​

▫️I (the child/adolescent client) have read the above,

​​ ▫️my parent(s)/guardian(s) have read the above,

▫️both my parent(s)/guardian(s) and myself have been given the opportunity to ask questions,

▫️have had all my and/or my parent(s)/guardian(s) questions answered to our contentment,

▫️consent to the counselling/therapeutic process.

• NOTE:Consent is an ongoing process and I have the right and ability to ask questions, seek out answers and play an active role in our treatment planning.

• Consent to treatment may be revised or withdrawn at any time.

 Child/ Adolescent client consent:

Signing below demonstrates that you (the child/adolescent client) and your parent(s)/guardian(s) have examined the guidelines defined above and understand the limits to confidentiality. If you have any questions as we advance with this therapeutic relationship, you can ask your Child and Youth Counsellor/Worker (Jen Carter) at any time.

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Child/Adolescent client’s Signature ​​ Date​​​​ ______________________

________________________________

Parent/Guardian Signature ​​​​​​ Date ______________________

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Jen Carter – CYCW ​​​​​​​ Date​​ ______________________            

Manager of Youth Programming

The Compass Rose Health and Wellness Centre​​​