Informed Consent Form

The purpose of this informed consent is to make you aware of your rights and responsibilities as a client and my rights and responsibilities as a counsellor. It will also provide you with the limits of confidentiality, give you some insight into the approach that I use, and what you can expect from participating in a counselling relationship with me.

I am a Registered Therapeutic Counsellor (RTC) and Master Therapeutic Counsellor (MTC) in good standing with the Association of Cooperative Counselling Therapists of Canada (ACCT). I am a graduate of the University of Victoria from which I received a BSc. with a double major in Psychology and Linguistics. I am also a graduate of Clearmind International Institute from which I received a diploma in Transpersonal Counselling. I am a Somatic Experiencing Practitioner and a Certified Clinical Trauma Professional from which I have membership with the International Association of Trauma Professionals.

I counsel from a combination of perspectives that include Clinical Trauma, Somatic Experiencing, Narrative Exposure Therapy, Cognitive Restructuring, Cognitive Behavior Therapy, Family Systems Theory, Transpersonal, Person Centered, Acceptance and Commitment Therapy and Gestalt orientations. I draw on the appropriate specialized skills necessary to stabilize and navigate my client successfully through treatment. Depending on your situation, we may examine patterns in your life that you may feel are not effective, look at the beliefs that drive them, and explore new options. We may also employ trauma therapy techniques as part of your treatment plan. This entails working with your nervous system to help release pain, trapped energy, sensations and emotions resulting from trauma, accidents, or injuries that cause illness and prevent injury.

During counselling strong emotions and feelings can arise. To overcome your personal problems you may have to draw on courage and persistence. You are not alone in this journey, we will work side by side.

As a Master Therapeutic Counsellor with the Association of Cooperative Counselling Therapists of Canada, I adhere to a strict code of ethics and confidentiality. All of the information that we share together is strictly confidential unless one of the following should occur:

1. The courts subpoena my files.
2. I am subpoenaed as a witness in court.
3. I suspect cases of child abuse that have not been previously reported. This includes physical harm, sexual abuse, sexual exploitation, and emotional harm. In this case I am required by law to report to the Ministry for Children and Families.
4. If you threaten to harm yourself or another. In this case I am also required to report this to the proper authorities.

On occasion I may consult with fellow professionals about the details of your case, without revealing your identity, to ensure that you receive the best care possible. All measures are taken to respect your privacy.

It is important for you to understand that you are the primary decision-maker in the direction your therapy takes, and therefore you have the right to full and active participation in the decisions that affect you. In addition, you have certain rights, which include the right to:

• receive an appropriate referral to other resources as needed.
• accept or reject any task, exercise or procedure suggested by me.
• be made aware of the rationale, risks, and benefits of any and all counselling interventions.

Fee Schedule:

My counselling fees are as follows:

• Initial session: $130 for 60 minutes
• Subsequent individual sessions: $130 for 60 minutes or $195 for 90 minutes
• Family or couples: $150 for 60 minutes or $225 for 90 minutes

Fees are preferred by e-transfer the day prior to each visit. Alternatively, I accept cheque, credit card, and e-transfer prior to your session (please e-transfer funds to jen@jenniferbrumcounselling.com). A $30 fee will be applied to all NSF cheques. Please note that counselling services provided by a Registered Therapeutic Counsellor are covered by some extended health benefits. I recommend you check with your extended medical or service provider to see if you have coverage. Payment is required up front and you can then submit your receipt to your insurance company for reimbursement if applicable.

You will be charged the full session fee for missed or cancelled appointments unless you have given at least 24 hours notice by email (jen@jenniferbrumcounselling.com) or telephone/voicemail (250-589-2786) in advance of your scheduled time. If you are late for a session I will be available to you only until the time our set appointment was scheduled to end and the full fee will be applicable.

If you do not understand fully any portion of this statement, or have questions about it, please do not sign below. You may request that we go over this disclosure and clarify any questions you may have.

In the event of a counselling crisis and you are unable to reach me please call the Vancouver Island Crisis Society @ 1-888-494-3888. They have trained crisis counsellors available by phone 24/7 to take your call.

By signing below, I indicate that I have fully read, understand, and agree with the above.