Contract of Counselling (Victoria)

Your Details

First Name *

Surname *

Postcode? *

House/Flat Number *

Your Counsellor

Select Your Contract? *

Date

Employee Support Program

Employer Support Session Contract

Sessions will take place at the agreed time and date which is pre-arranged between Counsellor & Client.

Drug/Alcohol use 
The client will abstain from using any non-prescribed drugs, and alcohol on the day of the prior agreed counselling appointment. The counsellor will end the session if the client is using Drugs or Alcohol on the day of the session.

Confidentiality 
All the sessions are confidential between the counsellor and the client.
 
There are some limits to confidentiality:
• The clinical service manager has access to all clinical records 

• Counsellors/Psychotherapists regularly present their work in clinical supervision. The aim of this is to monitor and improve the clinical work undertaken. All supervision is done on a confidential basis and only using the client’s first name. 

• All D4D practitioners work with a medical cover. They may at times need to contact your GP or other professional involved. This would normally be done with your permission and would be discussed in the session prior to any contact. However, if yours or another person’s safety is severely jeopardised the practitioner may contact the external services without the prior discussion.

• There are some legal limits to confidentiality such as Prevention of Terrorism and Drug Trafficking Acts. 

• If the client meets the counsellor unintentionally at a social event, the client has permission to greet the counsellor, the counsellor will not approach the client.

Confidential Record Keeping
Deaf4Deaf keep session case notes to a minimum. 

The information recorded includes:
●  Client name, date of birth, address and GP details
●  Information that  relates to the counselling process
●  Confidential case notes, describing the main focus of the session and any other important information

Pre-Session Assessments
On the day of each session, the client is required to complete the Pre-Session Assessment, you will have received this webpage link and directions to the webpage via the Deaf4Deaf website by email. 

Confidentiality
The Pre-Session Assessments will be shared with the Employee Assisted Companies Case Manager, Deaf4Deaf Operations Manager & Your Counsellor ONLY.

Disclosure

In exceptional circumstances when Deaf4Deaf believe there is a risk to your well-being, health or safety, or that of others (e.g., suicide, murder). At such times Deaf4Deaf will not need your permission to pass on essential information to the relevant person(s) (e.g., police, your GP).

Cancellation Policy

If a client cancels the session with less than 48 hours notice of the appointment time, or if the client is not available for the session at the agreed time, the session will be lost from the total number of agreed sessions authorised by the EAP company.

Length of each session?

Each Counselling session is for 50 minutes in duration.

Cost to Client?

There is no cost to the client for sessions funded by the Employee Assisted Company up to the number of sessions authorised.

Contract Confirmation Statement

I have read the Terms & Conditions of the Deaf4Deaf counselling contract. I agree with its contents and with my signature, I agree to its terms and conditions.

Signature *

Clear

Super 6 Funded Sessions Contract

Super 6 Contract

Sessions will take place at the agreed time and date which is pre-arranged between Counsellor & Client.

Drug/Alcohol use 
The patient will abstain from using any non-prescribed drugs, and alcohol on the day of the prior agreed counselling appointment. The counsellor will terminate the session if the patient is using Drugs or Alcohol on the day of the session. The session is considered lost and payment is still expected. 

Confidentiality 
All the sessions are confidential between the counsellor and the client. 

There are some limits to confidentiality:
• The clinical service manager has access to all clinical records.
• Counsellors/Psychotherapists regularly present their work in clinical supervision. The aim of this is to monitor and improve the clinical work undertaken. All supervision is done on a confidential basis and only using the client’s first name. 
• All D4D practitioners work with a medical cover. They may at times need to contact your GP or other professional involved. This would normally be done with your permission and would be discussed in the session prior to any contact. However, if yours or another person’s safety is severely jeopardised the practitioner may contact the external services without the prior discussion.
• There are some legal limits to confidentiality such as Prevention of Terrorism and Drug Trafficking Acts. 
• If the patient meets the counsellor unintentionally at a social event, the patient has permission to greet the counsellor, the counsellor will not approach the patient.

Confidential Record Keeping (Data Protection)
Deaf4Deaf keep session case notes to a minimum. 
The information recorded includes:
● Patient name, date of birth, address and GP details
● Information that relates to the counselling process
● Confidential case notes, describing the main focus of the session and any other important information
● Patients counselling contract

Disclosure

In exceptional circumstances when Deaf4Deaf believe there is a risk to your well-being, health or safety, or that of others (e.g., suicide, murder). At such times Deaf4Deaf will not need your permission to pass on essential information to the relevant person(s) (e.g., police, your GP).

Super 6 is?

6 x 50 minute sessions paid in advance

Super 6 (NO REFUND) Agreement

The Super 6 session fees are discounted by £10 per session, this enables to counselling more affordable therefore fees are not refundable.

Payment Policy

Fees will be paid before the first session commences in full, £228. (in exceptional circumstances Deaf4Deaf can agree to a stepped payment method)
If a client wishes to stop counselling before the end of the treatment plan of 6 sessions, there will be no return of fees on outstanding sessions.

Cancellation Policy

If you cancel the session with less than 48 hours’ notice of the appointment time, or if you are not available for the session at the agreed time, the funded session will be lost from the total number of sessions paid

How Would You Like To Pay?

Your Payment

How would you like to pay for your Super6? *

Bank Transfer or Paypal

Please Use the following Bank Account Details to Transfer £228:
Bank Details: Sort Code: 08-93-00
Account Number 04288129
Please Make Cheques Payable to Deaf4Deaf ltd
Remittance Address 25 Pembroke Avenue, Hersham, KT12 4NT


PayPal
https://www.deaf4deaf.com/payments-page/

Confirmation

The payment must be received before the first session of counselling starts.

Privately Paid by Session Contract

Sessions will take place at the agreed time and date which is pre-arranged between Counsellor & Client.

Cancellation Policy
If a client cancels the session with less than 48 hours notice of the appointment time, or if the client is not available for the session at the agreed time, the session will be charged at the agreed counselling fee.

Drug/Alcohol use 
The client will abstain from using any non-prescribed drugs, and alcohol on the day of the prior agreed counselling appointment. The counsellor will end the session if the patient is using Drugs or Alcohol on the day of the session.

Confidentiality 
All the sessions are confidential between the counsellor and the client.
 
There are some limits to confidentiality:
• The clinical service manager has access to all clinical records 
• Counsellors/Psychotherapists regularly present their work in clinical supervision. The aim of this is to monitor and improve the clinical work undertaken. All supervision is done on a confidential basis and only using the client’s first name. 
• All D4D practitioners work with a medical cover. They may at times need to contact your GP or other professional involved. This would normally be done with your permission and would be discussed in the session prior to any contact. However, if yours or another person’s safety is severely jeopardised the practitioner may contact the external services without the prior discussion.
• There are some legal limits to confidentiality such as Prevention of Terrorism and Drug Trafficking Acts. 
• If the patient meets the counsellor unintentionally at a social event, the patient has permission to greet the counsellor, the counsellor will not approach the patient.

Confidential Record Keeping
Deaf4Deaf keep session case notes to a minimum. 
The information recorded includes:
●  Patient name, date of birth, address and GP details
●  Information that  relates to the counselling process
●  Confidential case notes, describing the main focus of the session and any other important information

Disclosure

In exceptional circumstances when Deaf4Deaf believe there is risk to your well-being, health or safety, or that of others (e.g., suicide, murder). At such times Deaf4Deaf will not need your permission to pass on essential information to the relevant person(s) (e.g., police, your GP).

Session Payment

Each session will be paid before the session starts by Bank Transfer or PayPal or Credit/Debit Card, you can also Pay the Counsellor at the start of the counselling session.

Cancellation Policy

If a client cancels the session with less than 48 hours notice of the appointment time, or if the client is not available for the session at the agreed time, the session will be charged at the agreed counselling fee.

Contractual Payment

How Would You Like To Pay? *

Your Contractual Payment is? *

Payment Confirmation

Each payment must be received before the session of counselling starts.

NHS Funded Counselling

NHS Funded Contract

Sessions will take place at the agreed time and date which is pre-arranged between Counsellor & Client.

Drug/Alcohol use 
The client will abstain from using any non-prescribed drugs, and alcohol on the day of the prior agreed counselling appointment. The counsellor will end the session if the patient is using Drugs or Alcohol on the day of the session.

Confidentiality 
All the sessions are confidential between the counsellor and the client.
 
There are some limits to confidentiality:
• The clinical service manager has access to all clinical records 
• Counsellors/Psychotherapists regularly present their work in clinical supervision. The aim of this is to monitor and improve the clinical work undertaken. All supervision is done on a confidential basis and only using the client’s first name. 
• All D4D practitioners work with a medical cover. They may at times need to contact your GP or other professional involved. This would normally be done with your permission and would be discussed in the session prior to any contact. However, if yours or another person’s safety is severely jeopardised the practitioner may contact the external services without the prior discussion.
• There are some legal limits to confidentiality such as Prevention of Terrorism and Drug Trafficking Acts. 
• If the patient meets the counsellor unintentionally at a social event, the patient has permission to greet the counsellor, the counsellor will not approach the patient.

Confidential Record Keeping
Deaf4Deaf keep session case notes to a minimum. 
The information recorded includes:
●  Patient name, date of birth, address and GP details
●  Information that  relates to the counselling process
●  Confidential case notes, describing the main focus of the session and any other important information

Disclosure

In exceptional circumstances when Deaf4Deaf believe there is risk to your well-being, health or safety, or that of others (e.g., suicide, murder). At such times I will not need your permission to pass on essential information to the relevant person(s) (e.g., police, your GP).

Length of each session?

Each Counselling session is for 50 minutes in duration.

Application for Further Sessions

The NHS has awarded a set number of sessions for the client, the NHS will not guarantee any further sessions awarded after the initial total number of sessions awarded. If there is a requirement for further sessions Deaf4Deaf will apply for the number of sessions recommended by the counsellor. The NHS will deliberate over the application and decide if there is any further funding agreed.

NHS Further Session Funding Confirmation

A further set of funding is AGREED or DECLINED by the NHS, Deaf4Deaf do not Guarantee further funding will be agreed.

The Timescale for Further Funding Application

The NHS DO NOT GUARANTEE to make a decision on the client’s case within any set number of weeks of receiving further application for funding.

NHS Cancellation Policy

If a client cancels the session with less than 48 hours notice of the appointment time, or if the patient is not available for the session at the agreed time, the funded session will be lost from the total number of sessions awarded.
If the client misses two consecutive sessions without prior notice, the patients funding will be sent back to the NHS as per their policies.

How Many Counselling Sessions have you been awarded? * How Many Counselling Sessions have you been awarded?

Cost to Client?

There is no cost to the client for sessions funded by the NHS

Declaration NHS

Contract Confirmation Statement

I have read the Terms & Conditions of the Deaf4Deaf NHS paid counselling contract. I agree with its contents and with my signature, I agree to its terms and conditions.

Signature

Clear

Declaration Paid by Session

Contract Confirmation Statement

I have read the Terms & Conditions of the Deaf4Deaf paid by session counselling contract. I agree with its contents and with my signature, I agree to its terms and conditions.

Signature *

Clear

Donation Fund Contract of Counselling

Donation Free Counselling

Sessions will take place at the agreed time and date which is pre-arranged between Counsellor & Client.

Cancellation Policy
If a client cancels the session with less than 48 hours notice of the appointment time, or if the client is not available for the session at the agreed time, the session will be charged at the agreed counselling fee.

Drug/Alcohol use 
The client will abstain from using any non-prescribed drugs, and alcohol on the day of the prior agreed counselling appointment. The counsellor will end the session if the patient is using Drugs or Alcohol on the day of the session.

Confidentiality 
All the sessions are confidential between the counsellor and the client.
 
There are some limits to confidentiality:
• The clinical service manager has access to all clinical records 
• Counsellors/Psychotherapists regularly present their work in clinical supervision. The aim of this is to monitor and improve the clinical work undertaken. All supervision is done on a confidential basis and only using the client’s first name. 
• All D4D practitioners work with a medical cover. They may at times need to contact your GP or other professional involved. This would normally be done with your permission and would be discussed in the session prior to any contact. However, if yours or another person’s safety is severely jeopardised the practitioner may contact the external services without the prior discussion.
• There are some legal limits to confidentiality such as Prevention of Terrorism and Drug Trafficking Acts. 
• If the patient meets the counsellor unintentionally at a social event, the patient has permission to greet the counsellor, the counsellor will not approach the patient.

Confidential Record Keeping
Deaf4Deaf keep session case notes to a minimum. 
The information recorded includes:
●  Patient name, date of birth, address and GP details
●  Information that  relates to the counselling process
●  Confidential case notes, describing the main focus of the session and any other important information

Donation Fund Cancellation Policy

If a client cancels the session with less than 48 hours notice of the appointment time, or if the client is not available for the session at the agreed time, the session will be lost reducing your 6 sessions by the number of sessions missed.

Donation Fund Disclosure

In exceptional circumstances when Deaf4Deaf believe there is a risk to your well-being, health or safety, or that of others (e.g., suicide, murder). At such times Deaf4Deaf will not need your permission to pass on essential information to the relevant person(s) (e.g., police, your GP).

Donation Fund Session Payment

Each session will be paid by the Donation Fund

Your Donation Fund Payment is?

Donation Fund, How Many Counselling Sessions have you been awarded? *

Donation Fund Contract Confirmation Statement

I have read the Terms & Conditions of the Deaf4Deaf Donation Fund counselling contract. I agree with its contents and with my signature, I agree to its terms and conditions.

Donation Fund Signature *

Clear

Assessment Session Contract of Counselling

Assessment Session Contract

Sessions will take place at the agreed time and date which is pre-arranged between Counsellor & Client.

Cancellation Policy
If a client cancels the session with less than 48 hours notice of the appointment time, or if the client is not available for the session at the agreed time, the session will be charged at the agreed counselling fee.

Drug/Alcohol use 
The client will abstain from using any non-prescribed drugs, and alcohol on the day of the prior agreed counselling appointment. The counsellor will end the session if the patient is using Drugs or Alcohol on the day of the session.

Confidentiality 
All the sessions are confidential between the counsellor and the client.
 
There are some limits to confidentiality:
• The clinical service manager has access to all clinical records 
• Counsellors/Psychotherapists regularly present their work in clinical supervision. The aim of this is to monitor and improve the clinical work undertaken. All supervision is done on a confidential basis and only using the client’s first name. 
• All D4D practitioners work with a medical cover. They may at times need to contact your GP or other professional involved. This would normally be done with your permission and would be discussed in the session prior to any contact. However, if yours or another person’s safety is severely jeopardised the practitioner may contact the external services without the prior discussion.
• There are some legal limits to confidentiality such as Prevention of Terrorism and Drug Trafficking Acts. 
• If the patient meets the counsellor unintentionally at a social event, the patient has permission to greet the counsellor, the counsellor will not approach the patient.

Confidential Record Keeping
Deaf4Deaf keep session case notes to a minimum. 
The information recorded includes:
●  Patient name, date of birth, address and GP details
●  Information that  relates to the counselling process
●  Confidential case notes, describing the main focus of the session and any other important information

Assessment Session Cancellation Policy

If a client cancels the session with less than 48 hours notice of the appointment time, or if the client is not available for the session at the agreed time, the session will be lost to you with no further appointment to be made.

Assessment Session Disclosure

In exceptional circumstances when Deaf4Deaf believe there is a risk to your well-being, health or safety, or that of others (e.g., suicide, murder). At such times Deaf4Deaf will not need your permission to pass on essential information to the relevant person(s) (e.g., police, your GP).

Assessment Session Payment

The Assessment Session is Free to you.

Assessment Session Payment is?

Assessment Session Contract Confirmation Statement

I have read the Terms & Conditions of the Deaf4Deaf Assessment Session counselling contract. I agree with its contents and with my signature, I agree to its terms and conditions.

Assessment Session Signature *

Clear