Muriel E. McMahon
murielmcmahon@murielmcmahon.com
Informed Consent to Treatment Agreement
Muriel E. McMahon, RP, Jungian analyst, M.Ed. is a member in good standing with the College of Registered Psychotherapists of Ontario (CRPO # 001112), the International Association of Jungian Analysts (IAAP), and the Ontario Society of Registered Psychotherapists (OSRP). She is a Zurich trained Jungian analyst (ISAP, 2007) and is the sole proprietor of an online international psychoanalytic Jungian praxis. She has been working in the mental health and educational field for 30 years.
Muriel E. McMahon adheres to policies and procedures in compliance with the Personal Information Protection and Electronic Document Act, 2004 (PIPEDA) and the Personal Health Information Protection Act, 2004 (PHIPA).
I believe it is important that I have your informed consent before beginning analysis. By reviewing and agreeing to the information presented below, you will be informed about our analytical process, personal information handling, client record management, electronic communication policy, financial agreement, and the risks-benefits of online-analysis. Informed consent for analytical services is critical for client self-determination. Consent must be given voluntarily and knowingly. You have the right to change your mind and withdraw informed consent at any time.
Analytical and Therapeutic Process
Therapy and analysis are a collaborative process, where the analysand seeks to improve wellbeing and/or functioning with the assistance of a licensed mental health professional. The licensed professional utilizes their education and experience; however, the ultimate responsibility for improved functioning and wellbeing rests with the client(s). In addition, wellbeing and functioning are products of a wide range of factors that may be outside the influence of analysis. For these reasons, the outcomes of analysis cannot be completely guaranteed.
The benefits of analysis include but are not limited to personal growth through making what was formerly unconscious more conscious and in so doing aligning ones internal and external processes, enhancing goal achievement, development of coping strategies, increased self-awareness, and improvements in interpersonal relationships. However, risks of analysis include but are not limited to recalling unpleasant events which may lead to strong and/or unexpected changes in feelings, thoughts, and mood. Your analyst will work with you and your dreams and other unconscious material (creative expression, derivatives, synchronicities, active imagination, stories, etc.). to minimize the risks of analysis, calibrate our approach, and maximize the benefits of analysis; however, it is important that you are informed about the risks of analysis and the importance of regular monitoring of ego strength to contain and process unconscious material. I welcome any questions regarding my/our particular therapeutic approach and treatment plan.
Confidentiality
The content of all analytic sessions is considered to be strictly confidential. Both verbal information and written records about an analysand cannot be divulged by your analyst to be shared with any other party without the written consent of the analysand or the analysand’s legal guardian. At any time, you have the right to withhold or withdraw consent, or place conditions on the disclosure of your information. My service is committed to protecting the privacy of your personal information and has developed policies and procedures in compliance with the Personal Information Protection and Electronic Document Act, 2004 (PIPEDA) and the Personal Health Information Protection Act, 2004 (PHIPA).
As per standards of our profession and the College of Registered Psychotherapists of Ontario, I collect the following information: name, address, email address, phone numbers, date of birth, other contact information, names and contact information of others who are significant to your situation (family members, physicians, and other professionals). I also collect relevant information about our work together, any correspondence sent or received, any consents or other documents you have signed, copies of papers you have given us and other documentation particular to the nature of our involvement. Information necessary for billing purposes which may include information about your Assistance Program and their standards, information about other third-party payers, copies of all receipts given to you including copies of electronic payments, copies of invoices and billing records and information related to the scheduling of appointments with you.
There are exceptional situations where I am ethically, professionally, and/or legally required to share information about you and/or your situation without your written consent.
These situations include the following:
1. If I have information about the abuse or risk of abuse and/or neglect to a child (a child is a person who is, or appears to be, under the age of 16 years. It also applies to children subject to a child protection order who are 16 and 17 years old) then I must report this information to the appropriate authorities. Abuse includes but is not limited to physical violence, sexual violence, emotional violence, and/or neglect.
2. If I have concern about any risk that you may harm another person or yourself then I am obligated to ensure your safety and the safety of others by informing the appropriate services and/or individuals.
3. If I am compelled by law to release information, such as receiving a subpoena to court.
4. When disclosure is required to receive professional or legal consultation.
5. If I must defend a complaint filed with the CRPOor any other court action.
These exceptions to confidentiality are rare; however, it is important that you are aware of the possibility of these confidentiality exceptions. Additionally, to assist in providing my analysands with the highest quality of service, I may also share pertinent anonymous information within the confidential space of individual, group, and peer supervision and/or consultation. Please keep in mind that all identifying information will remain strictly confidential during supervision and/or consultation.
I utilize Personal Information Protection and Electronic Document Act, 2004 (PIPEDA) and the Personal Health Information Protection Act, 2004 (PHIPA) compliant electronic records for storing your information. Your file contains all the personal information about you and your situation with the exception of copies of billing information such as receipts and electronic payments. Your file is only stored on highly secure encrypted devices. Your file is maintained according to regulations set by our profession and in accordance with other legal requirements. In the event of incapacity or death of your analyst, a designated custodian would have some access to your information in order to assist you in a transfer to another therapist or to maintain the file according to legal and regulatory standards. This custodian would be required to adhere to the same professional standards as your analyst.
I will ensure the security and preservation of your record for a period of 10 years after the last date of service provided. You have the right to request to see any personal information that I have collected about you or your situation. You have the right to review your clinical file. I will assist you to understand all of what has been written in your file. If you believe that some information about you is incorrect, you may request that the information be changed. I will then correct this information with any third parties who may have been given the wrong information. If you wish to view your file or if you have any concerns about the privacy of your information, please contact me.
Emergency or Policy
Please note that my service does not provide emergency or crisis support. In the event of crisis, emergencies, or the need for immediate emotional support, please contact a Mental Health Crisis line such as Distress Centers, call 911, or go to your nearest emergency room. Please note, I do not regularly check my email, nor do I respond immediately, so these methods should not be used if there is an emergency.
Electronic Communication Policy
Many of these common modes of communication put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law. If you have any questions about this policy, please feel free to discuss this with me.
Email Communications
I use email communication only with your permission and only for administrative purposes unless we have made another agreement. That means that email exchanges should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters because email is not a secure way to contact me. If you need to discuss a clinical matter, please feel free to email me to set-up an earlier appointment, I will attempt to respond within 24 hours except on weekends or holidays. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room (please review our emergency/ crisis policy above). If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact in my absence if necessary.
Text Messaging
Regular text messaging is not a very secure mode of communication. Texts are only used to send reminders and confirm appointment times.
Social Media
I do not communicate with, or contact, any of my clients through social media platforms like Twitter and Facebook. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. This is because these types of casual social contacts can create significant security risks for you. I participate on various social networks, but not in my professional capacity. If you have an online presence, there is a possibility that you may encounter me by accident. If that occurs, please discuss it with me during our time together. I believe that any communications with clients online have a high potential to compromise the professional relationship. In addition, please do not try to contact me in this way. I will not respond and will terminate any online contact no matter how accidental.
Websites
I have a website, www.murielmcmahon.com that you are free to access. I use it for professional reasons to provide information to others about me and my practice. You are welcome to access and review the information that I have on my website and, if you have questions about it, please discuss this during your therapy sessions.
Web Searches
I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment.
Recently it has become common for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy.
Online Counselling Informed Consent
I have been highly selective in choosing a private and confidential video conferencing service that has an encrypted connection and is both PHIPA (Personal Health Information Protection Act) and HIPAA (Health Insurance Portability and Accountability Act of 1996) compliant. However, I feel it is important that you are aware of the unique benefits and risks of online analysis. Please read this carefully and let me know if you have any questions. When you sign this document, it will represent an agreement between us.
Benefits and Risks of Online Analysis
Online analysis refers to providing analysis services remotely using telecommunications technologies, such as video conferencing. One of the benefits of online analysis is that the analysand and analyst can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the analysand or analyst moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Online analysis, however, requires technical competence on both our parts to be helpful. Although there are benefits of online analysis, there are some differences between in-person analysis and online analysis, as well as some risks.
For example:
- Risks to confidentiality. Because online analysis sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in analysis only while in a room or area where other people are not present and cannot overhear the conversation.
- Issues related to technology. There are many ways that technology issues might impact online analysis. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies. Additionally, you may have to have certain computer or cell phone systems to use online analysis services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in online analysis.
- Crisis management and intervention. Usually, I will not engage in online analysis with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in online analysis, please review my crisis/ emergency policy.
- Efficacy. Most research shows that online analysis is about as effective as in-person analysis. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely.
Online Confidentiality
I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of our online analysis. However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for online sessions and having passwords to protect the device you use for online sessions).
The extent of confidentiality and the exceptions to confidentiality that were outlined for in-person analysis still apply in online analysis. Please let me know if you have any questions about exceptions to confidentiality.
Emergencies and Technology
Assessing and evaluating threats and other emergencies can be more difficult when conducting online analysis than in traditional in-person therapy. To address some of these difficulties, we will create an emergency plan before engaging in online services. I will ask you to identify an emergency contact person who is near your location and who I will contact in the event of a crisis or emergency to assist in addressing the situation. I will ask that you sign authorization allowing me to contact your emergency contact person as needed during such a crisis or emergency.
If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call me back; instead, call 911, Distress Centers, or go to your nearest emergency room. Contact me after you have called or obtained emergency services.
If the session is interrupted and you are not having an emergency, disconnect from the session and I will wait two (2) minutes and then re-contact you via the online platform on which we agreed to conduct analysis. If you do not receive a call back within two (2) minutes, then email me and we will make appropriate arrangements.
If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.
Payment for Online Services
The same fee rates will apply for online analysis as apply for in-person analysis. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication or online. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic therapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in online sessions in order to determine whether these sessions will be covered.
Online Recording
The online counselling sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I will maintain a record of our session in accordance with my policies.
Statement of Informed Consent
I have read and fully understand the information contained in this Informed Consent to Treatment document. Any and all questions I have regarding the contents of this document have been answered to my satisfaction and I would like to proceed with individual analysis.
Financial Agreement and Disclosure
In compliance with ethics and standards, it is required to disclose all billing and financial matters regarding your treatment. As a client of Muriel E. McMahon, you understand:
Payment
Analysands are encouraged to set-up the payment tool within the online analysis service. At the end of each session, the analyst will use the online payment tool to bill the analysand at the agreed upon rate and issue a receipt.
• Your fees will be discussed with you during the initial consult as fees vary according to the time and nature of the service involved.
• The fee is set on a fee-for-service basis and the hourly rate is determined by your analyst upon review of your Intake Form. A analytical hour is considered 50 minutes.
• I also accept e-transfer, debit/credit card (Visa, Master Card, Discovery), PayPal.
• A full session fee is charged for missed appointments, cancellations or appointment change requests with less than 24 hour notice, unless it is due to illness or an emergency. An invoice will be sent to clients who do not show up, cancel an appointment or appointment change requests.
• If you need to contact your counsellor between sessions during the course of therapy, emails will be picked up periodically throughout the day. There will be no charge for administrative emails.
• The cost of providing written reports to a third party will be negotiated prior to the report being prepared.
• Receipts will be provided for income tax purposes if applicable.
Insurance Reimbursement
• Psychological services ARE NOT covered by O.H.I.P. but are often partially or fully covered by extended insurance plans. Various plans differ when covering counselling via a Registered THERAPIST/COUNSELLOR, so please contact your specific provider for coverage details and claim procedures.
• You are fully responsible for all aspects of extended health care, and/ or forms of financial reimbursement made available to you.
• Some insurers require a formal referral from a physician in order to provide coverage. Please check with your plan.
• Receipts will be provided for insurance purposes if applicable. Please feel free to discuss any questions or concerns you may have regarding the financial aspect of your counselling services.
I have read and fully understand the information contained in this Financial Agreement and Disclosure document. Any and all questions I have regarding the contents of this document have been answered to my satisfaction and I would like to proceed with individual counselling.
E-mail Consent
I understand that Muriel E. McMahon will occasionally send and receive e-mail from clients. I understand that I am solely responsible for the security of e-mails I send and receive, also that Muriel E. McMahon is not responsible for a breach of privacy, confidentiality or security of emails I send and receive.
Last updated on June 16, 2023