Starry Wonderland Play Therapy

Consent Form

Welcome to my practice. I am happy you are here! I am a Registered Social Worker (#16015) with the British Columbia College of Social Workers, and I hold a master’s degree in social work. I am also a Registered Play Therapist (RPT) with the Association for Play Therapy (United States). I have prepared this letter to inform you about my policies, as well as your own rights as a counselling client. Please read it carefully before signing and talk with me about any questions you may have.

Counselling Services:

I, the undersigned parent/guardian, hereby consent to my child’s participation in play therapy counselling services provided by Starry Wonderland Play Therapy and its therapists. I understand that play therapy is a specialized form of counselling that uses play as a means of communication and expression for children. Play therapy aims to support the child’s emotional, behavioral, social, and psychological well-being.

Confidentiality:

I understand that the play therapy sessions are confidential, and the information shared during these sessions will be treated with the utmost respect for privacy and confidentiality. I acknowledge that confidentiality is subject to certain legal and ethical limitations, which include:

1. Duty to Warn: If there is a serious threat of harm to the child or others, the therapist may be required to disclose pertinent information to the appropriate authorities or take necessary actions to ensure safety.
2. Child Abuse or Vulnerable Adult Abuse: If the therapist has reason to suspect child abuse or abuse of a vulnerable adult, they are obligated to report such suspicions to the appropriate authorities.
3. Court Orders or Subpoenas: Confidentiality may be waived if a court of law issues a valid subpoena or court order requiring the disclosure of counselling records.

Parent/Guardian Involvement and Communication:

I understand that my involvement as a parent/guardian is an important part of the play therapy process. The therapist may request periodic meetings or consultations with me to discuss my child’s progress, treatment goals, and any concerns that may arise. I agree to actively participate in these meetings and provide relevant information that may assist in the counselling process.

Rights and Responsibilities:

I understand that as a parent/guardian, I have the following rights:

1. To be treated with respect, dignity, and professionalism.
2. To ask questions and seek clarification on any aspect of the play therapy process.
3. To be informed about the goals, techniques, and progress of my child’s play therapy sessions.
4. To consent or make decisions regarding any modifications to the play therapy treatment plan.

I also accept the following responsibilities:

1. To ensure my child attends scheduled play therapy sessions regularly and on time.
2. To communicate any concerns, changes in circumstances, or relevant information that may impact the play therapy process.
3. To support my child’s engagement in play therapy and encourage their active participation.

Fees and Cancellation Policy:

I understand the play therapy counselling services fees are $165 (inc. tax)/ 50-minute session. I am aware of the cancellation policy, which requires emailing the therapist at swptbc@gmail.com 48 hours before the scheduled appointment to avoid a charge of the full fee for a missed appointment. Fees are due and payable by cash, cheque, or e-transfer at the end of each session.

Counselling Records:

I understand and acknowledge that the therapist will keep records of the counselling sessions, which may include written notes and other forms of documentation. I consent to the therapist’s use of these records for the following purposes:

1. Treatment Planning: The records may be used to assess progress, develop treatment plans, and inform therapeutic interventions.
2. Consultation: The therapist may consult with a clinical supervisor for the purpose of enhancing the effectiveness of the counselling services.
3. Legal and Ethical Requirements: The records may be disclosed as required by law, professional ethics, or court orders.

Audio or Video Records for Supervision:

The therapist may take audio or video recordings of the counselling sessions, solely for the purpose of consulting a clinical supervisor to enhance the effectiveness of the counselling services, and the therapist will destroy the records after the supervision.

Consent: