My therapist, Modya Silver, has expressed how he conducts a therapy session and as a result I understand that therapy has benefits that can include, but are not limited to, gaining self-awareness, self-expression and self-agency to ease emotional distress, disturbing thoughts, and to address relationship issues with myself and others. I understand that through therapy I may start to feel a greater sense of empowerment and resilience. I also understand that there are risks in therapy and that I may experience strong emotions, such as sadness, anxiety, loneliness, and other difficult or painful thoughts, feelings, and body sensations both in and outside of therapy sessions. Despite my best intentions, and the best intentions of my therapist, it’s possible that I may leave a therapy session feeling exposed and that the raw feelings are part of the growth in this work.

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Given the above potential benefits and risks, I understand that I need to discuss my emotional states, sense of resistance to therapeutic suggestions and progress with my therapist in an ongoing fashion in order to make adjustments to the therapy, to end therapy, and/or to consider alternatives to therapy if/when necessary.

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I understand that I have the following rights with respect to therapy:

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I understand that Modya Silver practices Gestalt Therapy, a relational humanistic model that focuses on experiences in the here-and-now. He also practices Somatic Experiencing® and may draw on other therapy techniques and theories. Throughout a therapy session, he may suggest exercises that help explore emerging challenges. I understand that I have the right to withhold or withdraw consent at any time to all or part of the work with Modya without affecting my right to future care or treatment with him.

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​The information I disclose during the course of my therapy is confidential. However, there are limits to confidentiality in which Modya has a duty to report to appropriate agencies and authorities where he believes on reasonable grounds that it is necessary. These circumstances include:

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• An imminent suicide attempt, harm to self, or where my safety is in jeopardy

• Reporting child, elder, and dependent-adult abuse

• Reporting expressed threats of violence towards a victim

• Sexual abuse by another health professional

• Responding to a legally enforceable warrant or subpoena

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In addition, I understand that Modya may discuss some confidential material with his supervisor or in peer supervision, as is consistent with professional protocols. If I ask Modya to speak to another healthcare provider about anything related to my work with him, he will ask me for a signed consent form first that describes my acceptance and limits of what he can disclose.

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I understand that I have a right to access my file and copies of records upon my request, subject to reasonable notice.

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I have a right to a receipt for therapy services upon my request, subject to reasonable notice.

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I understand that Modya is a certified member of the College of Registered Psychotherapists on Ontario. He also is a member of the Ontario Society of Registered Psychotherapists and as such he is subject to the code of ethics of these professional organizations.

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I understand that I have the following responsibilities with respect to therapy:

 

Process: I recognize that therapy is a mutual process in which there is a shared responsibility for decision making for goals and treatments. My responsibility includes the recognition of my own agency and capacity for choice and the necessity that I be engaged in the creation, development, and enactment of all therapeutic processes. If I have any questions or feel uncomfortable with the process of therapy, I understand that I have the right to bring these issues up in conversation. I may ask for a referral to another practitioner if I choose. I understand that I may communicate with my therapist by phone call, text, video or email and that these communications are not fully confidential due to the public nature of the telecommunications networks.

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Meeting: The therapy sessions may take place at Modya's office, over digital video communications or by telephone. I understand that Modya is making best efforts to ensure privacy through any of these modalities.

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Fee: I agree to be responsible for the fee for a 55 minute individual session. I understand further that I will be given reasonable notice before any anticipated change of fees.

 

I understand that payment is to be made in the following way:

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1. If I choose Interac e-Transfers, I am expected to pay prior to the session.

2. If I choose to pay by cash, I am expected to pay at the end of each session.

 

I agree to pay for therapy services on the day they are delivered, unless other arrangements are agreed upon. If my circumstances change, I can discuss a change of fee. At any time, if I want to end therapy, I may do so with a week’s notice to my therapist, but I may not withhold fees for sessions already given or any future sessions in which I continue to participate.

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Cancellation: I understand that there is a 48-hour cancellation notice requirement. I agree to be responsible for payment for any scheduled session I do not attend if I have not given at least 48 hours notice. I understand that this notice does not apply to emergency situations, in which cases I agree to give as much notice as possible.

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Medications: I will notify Modya of my prescription medications and any changes in their usage.

I agree to share information regarding my mental and physical health as assessed by previous practitioners, including any disagreements I may have with their assessment.

 

I understand that if Modya believes that my needs are beyond the scope of his practice, that he will give me a referral to another practitioner, if he is able.

 

In the event that I am considering terminating treatment with Modya, I will consider attending at least one session to discuss it with him in person.

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I have read and understand the information provided above, and understand that our first session, we will have a chance to discuss any part of this document further.  I hereby consent to therapy treatment with Modya understanding that a verbal consent is still required prior to any therapy being conducted.

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