Fillable Printable Momentum Counselling Contract Template

Momentum Counselling Contract Template

Momentum Counselling Contract

Agreement between (list all names)__________________________________________

(referred to as “you”, “your” and “client”) and Momentum Counsellor / _______(referred

to as “I”, “me”, “my”, “therapist” and “Momentum CS”).

Aim of Counselling: The aim of counselling is to provide you, the client, with a confidential

opportunity to explore personal and relational issues in safety. The role of Momentum CS is to help you through this process

without judgement or telling you what to do. I may on occasions give information or offer suggestions. During counselling, we

set goals agreed between the client and the therapist. The client agrees to work towards the agreed goals. If at any time I feel I

can no longer help you, I will offer to refer you to someone who can.

Description of therapy: A full description of my therapy can be found at www.dundeecounselling.com/about/our-therapy.php

Confidentiality: To ensure open exploration of the concerns that have brought you to therapy, Momentum CS maintains

confidentiality in accordance with the British Association of Counselling and Psychotherapy (BACP) Ethical Framework for Good

Practice in Counselling & Psychotherapy (Code of Ethics) – see www.bacp.co.uk. I am a member of the BACP and bound by their

Code of Ethics.

Under the same BACP Code of Ethics, Momentum CS keeps client records (short summaries about what happens in session).

Momentum CS adheres to the Data Protection Act of 1998 see www.legislation.gov.uk/ukpga/1998/29/contents.

Counsellors and therapists of Momentum CS receive regular supervision in accordance with the BACP Code of Ethics to provide

the best possible service to you. Supervisors of Momentum CS counsellors and therapists abide by the same standards for

confidentiality.

Exceptions to Confidentiality: Momentum CS must pass on any information to the relevant authorities in cases where human

safety is concerned including the following cases:

1. If you threaten harm to yourself or to another person

2. If we believe a child or protected adult is at risk of harm or abuse

3. If the courts instruct us to give information

4. If you share information about a proposed act of terrorism or other illegal act

If Momentum CS feels that either you or someone else is in danger or at risk of harm I would first endeavour to discuss with you

my decision for breaking confidentiality. Depending on the circumstances this may be your General Practitioner (GP), the

individual in danger, a Social Worker and/or the Police. However, I retain the right to break confidentiality without prior

consultation with you should I consider that the urgency of the situation requires me to act immediately to safeguard the

physical safety of yourself or others.

In certain cases, you, the client, may request that Momentum CS share information concerning you. In these cases I require

written permission from you before I can carry out your request.

Confidentiality for Couples, Families and Groups: When couples, families or groups meet for relationship counselling at

Momentum CS, sometimes the clients will meet all together for counselling and sometimes they may meet individually with the

therapist. When individuals attend counselling sessions the therapist will not reveal any confidential information shared in an

individual session with partners, other family or group members involved in relationship counselling without the prior written

permission of that individual.

Sessions: Sessions last approximately 50 minutes and will be every week typically on the same day and time, suitable to you and

within my hours of operation (refer to www.dundeecounselling.com). It is expected that the session will begin at the agreed

time. Any session that begins after this time due to late client arrival for whatever reason cannot be extended beyond the

agreed finish time. If you do not arrive or call within 15 minutes of the agreed appointment, this will be considered a

cancellation and the therapist will not be available for the remainder of the session.

Contact between sessions: In instances where you need to contact me between sessions, calls can be made to (01382) 220 242.

If I am unable to take your call, please leave a message on the answering machine. Calls and messages will be responded to as

time permits between sessions within normal operating hours. Momentum Counselling is not a crisis or emergency service. If

you need to speak to someone immediately, please contact your GP, NHS 24 (08454 242424) or the Samaritans (08457 909090).

Cancellations: If for any reason I have to cancel a session I will aim to provide you with 48 hours’ notice, and you will not be

charged for the session. When possible I will try to offer you an alternative time. Likewise I will expect you to give me 48 hours’

notice if you are unable to attend. You will not be charged for appointments missed due to illness provided you give me at least

24 hours’ notice. I reserve the right to charge up to 75% of the agreed session fee for a missed session where no or insufficient

notice is given. In the event of a serious accident, emergency, or other similar situation outside your control, please deal with

your situation first and notify me at the earliest convenient time, or I will follow up with you typically within 24 to 48 hours of

the missed appointment.

Reducing missed appointments is the most effective method for us to maintain low client session fees. To help avoid missed

appointments we offer a free text reminder service. See below:

Holidays: I will give you a minimum of 3 weeks’ notice of any planned holiday dates when I will be unavailable. I require (where

possible) at least 2 weeks’ notice from you.

Number of Sessions: Momentum CS asks that you commit to 4 sessions before realistically evaluating the effectiveness of

therapy. After this, the contract can be renewed verbally for an additional 4 sessions. A review is given every 8

session (or

sooner if desired) and may include changes in dates and times or frequency of sessions. Part of the review process is to

determine if more sessions are necessary in order to reach your goals. If both therapist and client collaboratively agree that

more sessions are necessary, they contract for more sessions (usually 3 – 8) before ending therapy or reviewing the process

again.

I understand that your life circumstances may suddenly change. You may at any point desire or be obligated to discontinue

therapy. Whatever the reason, I respect your decision but ask that you give one weeks’ notice before finishing so that we have

the chance to discuss your decision.

Session Fees: Session fees are £30 per 50 minute session for adults and £25 for under 18’s. The fee is the same for individual or

couple counselling sessions. Fees are reviewed annually and any changes take effect on 1

January and apply to new or renewed

contracts.

Method of Payment: By cash, card or cheque at the beginning of each session. Multi Session purchase discounts are available.

There is an online payment method and specials from time to time listed on our website.

Complaints: Should you wish to make a complaint about the service you have been offered please contact the BACP at

www.bacp.co.uk.

How did you hear about us? □ Internet Search, □ BACP website, □ a friend, □ an advert, □ ………………………………………………………..

Goals for therapy…………………………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………………

Print Name……………………………………………………………………... Print Name…………………………………………………………………………………..

Signed................................................................................... Signed………………………………………………………………………………………….

Date...................................................................................... Date…………………………………………………………………………………………….

Phone…………………………………………………………………………….. Phone…….……………………………………………………………………………………

Email……………………………………………………………………………… Email……………………………………………………………………………………………

Address………………………………………………………………………………………....... City……………………………… Postcode………………………….

GP name(s)……………………………………………………………………………………………………………………………………………………………………………………

Surgery Name………………………………………………………………… Surgery Telephone………………………………………………………………………

Therapist, Signature……………………………………………………………………………………………………………………