Informed Consent for CBT Culture Clients

When I commence a new counselling relationship with a client, I ensure we enter a mutually agreed consent agreement. I have outlined the details of the agreement, that both of us sign, below.

​You can download the informed consent agreement here.

The Agreement

I, Debbie McMillan of CBT Culture, will demonstrate to you, the core values of therapy by:

​Kotahitanga/Partnership

• I will act with care and respect for individual and cultural differences and the diversity of human experience.
• I will avoid doing harm in all of my professional work.
• I will actively support the principles embodied in the Treaty of Waitangi.
• I will respect your confidentiality.
• I will promote the safety and well-being of individuals, families, communities, whanau, hapu and iwi.
• I will be pono/honest and trustworthy in my professional relationship with you
• I will practice within the limits of my expertise and if necessary, refer you to other therapists or counsellors who would be more appropriate by reason of their skills, gender or culture or for any other reason indicated by your needs.
• I shall take account of my own cultural identity and biases and seek to limit any harmful impact of these in my work with you.
• I will actively avoid discrimination against you on the basis of race, colour, disability, ethnic group, culture, gender, sexual orientation, social class, age, religious or political beliefs or any other basis.
• I will actively work with you in ways that are meaningful in the context of, and respectful towards your cultural communities.

​Matatapu/Confidentiality

• I will treat all communication between yourself and I as confidential and privileged information, unless you give me consent to particular information being disclosed.
• I may discuss, in supervision, information received in our sessions whilst maintaining your anonymity.
• I will take all reasonable steps to communicate clearly the extent and limits of the confidentiality I offer you.  Any agreement about confidentiality may be reviewed and changed by joint negotiation.
• I will protect your identity when information gained from our therapeutic relationship is used for purposes such as my professional development, research or audit.
• I will not acknowledge you outside of the therapeutic environment, nor confirm to others (with the exception of your referrer) that you are attending therapy unless you advise otherwise.

​Exceptions to Matatapu/Confidentiality:
I will only make exceptions to confidentiality in order to reduce risk;

• there is serious danger in the immediate or foreseeable future to yourself or others,
• your competence to make a decision is impaired,
• legal requirements demand that confidential material be revealed,
• responding to a complaint about my practice.

Wherever possible, the decision to make an exception to confidentiality is made:

• after seeking your co-operation, unless doing so would further compromise the safety of yourself or others,
• after consultation with a supervisor.

Putea/Fees

• Sessions are $69 (inclusive of GST) and payable on day of session.
• Report writing will be charged at the same rate as a session.
• Internet banking is preferred; CBT Culture BNZ 02-0278-0003513-002.
• No payment is required for an ACC sensitive claim.

Ngaro/Absence

• Due to the considerably discounted session fee all absences will incur a full fee, with the exception of emergencies.  This is also to encourage commitment and continuity of sessions, as these factors have been proven to lead to successful outcomes for therapeutic change.

Pukapuka/Documentation 

• All material about you or your therapy, recorded in any form (electronic, audio, visual and text), will be maintained in sufficient detail to track the sequence and nature of professional services provided.  Such records shall be maintained in a manner consistent with ethical practice taking into account statutory, regulatory, agency or institutional requirements.
• I will obtain your informed consent when writing reports for third parties.
• I will create, maintain, transfer and arrange to destroy documentation in a manner compliant with the requirements of the confidentiality sections of this agreement.
• You have the absolute right to access your documentation, to know how this information is being kept, to know who has access to it and to ask for a copy.

​Informed Whakaae/Consent
Your signature confirms informed consent; informed implies understanding and free consent implies a lack of pressure. I respect your right to refuse or withdraw consent at any time.