Informed Consent For Treatment And Cancellation Policy
Obtaining an informed consent form is necessary to ensure that you are aware of the treatment
being offered. Since each individual reacts differently to therapy, it is not possible to
predict all risks & reactions.
By submitting this informed consent form:
I understand that the treatments being provided to me or the person named below for whom I am
legally responsible to may include:
Traditional Talk Therapy
Professional (Work Related) Counselling
And I hereby request & consent to the performance of the above treatments on me.
I also understand that a session lasts 45 to 90 min & follow-up sessions will be
recommended after the first initial visit. For effective recovery it is advised to have 6-9
visits, depending on the client need.
I am aware of the risks outlined above & have discussed any concerns I may have regarding my
therapy. I do not expect the counsellor to be able to anticipate & explain all possible risks
& complications of treatment, & I wish to rely on the counsellor to exercise judgement
during the course of treatment which they think at the time, based upon the facts then known is
in my best interest. I understand results are not guaranteed.
I am consenting to the treatments offered by Catherine Holden or by her fellow counsellors &
to the treatments recommended by them as well. I have been told about the risks & have had an
opportunity to ask questions.
Since e-mail is not a totally confidential means of communication, please consider this as you
communicate with us. While we will make a reasonable effort to keep what is written private, it
is suggested that very personal information be communicated by phone, on paper, or in person.
If you are experiencing a life-threatening emergency, please call emergency services
(999/112/911) immediately. If this occurs during out of office hours, & is not an emergency,
please contact the therapist during office hours.
Cancellation is free, if done 24 hours in advance of the appointment. Please contact us through
e-mail or by phone (+254 713 896 905) to do so. We request that you also provide feedback on
why you have cancelled.
Rescheduling your appointment
If you wish to reschedule your appointment to an alternative date, please contact us at least 24
hours before appointment time through e-mail (firstname.lastname@example.org) or by phone (+254
713 896 905). You may reschedule an original appointment twice, after which your initial visit
fee will be forfeited.
The information contained in this form is confidential. It is intended solely for counsellor.