INFORMED CONSENT FORM
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Jane Clapp is Jungian Psychoanalyst and a Registered Psychotherapist with the CRPO.
Description of Services
Psychoanalysis is often an intensive process in terms of time and emotional impact but can lead to profoundly transformative changes in behaviour, quality of life, and self-understanding. Jungian Analysis, developed by Swiss psychiatrist Carl Jung, is a type of psychoanalysis that seeks to bring balance and union between the conscious and unconscious parts of the mind. Jungian Analysis is built on the belief that the human psyche, if given the proper conditions, has a natural tendency to heal and move toward wholeness. Although unconscious influences can greatly distort our thoughts, feelings, and relational patterns, the unconscious can also be a source of both wisdom and guidance.
My approach includes but is not limited to Jungian dream analysis, somatic emotional awareness practices, active imagination, resourcing you with tools for improved self-regulation, creative expression, and exploration into childhood histories and traumatic events. The overall aim is to provide an opportunity for people to work towards living more satisfyingly and authentically. Psychoanalytic relationships will vary according to need but may be concerned with developmental or mental health issues, addressing and resolving specific problems, making decisions, coping with crises, developing personal insights and knowledge, working through feelings of inner conflict or improving relationships with others.
You may face issues or aspects of yourself that are uncomfortable, and working with me may lead to unforeseen changes in your relationships or take you outside of your comfort zone to explore and expand your growing edge. Benefits may include an increased ability to live more effectively by improving your ability to cope with various stressors and life challenges. You may also gain a better understanding of yourself, your hopes for your life and your values, which will assist you in your personal and career path. You may experience relief or resolution of trauma symptoms and develop skills, increased resiliency and a healthier relationship with yourself and others.
Outcomes and Ethics
The outcome of our work together is difficult to predict or guarantee since it is dependent on several factors, such as the fit between you and me, current adverse conditions that are actively contributing to your symptoms, and your capacity and willingness to face difficult truths in your life. However, I will do my best to help you handle the risks safely and experience at least some of the benefits. If you have any questions or concerns, I encourage you to discuss them with me at any point.
Confidentiality
I respect clients' privacy, hold all information about clients in strict confidence, and comply with applicable privacy and other legislation. Without prior written authorization, no information will be released to a third party. At any time, you have the right to withhold or withdraw consent to or place conditions on the disclosure of your information.
Exceptions to confidentiality include the legal and/or ethical obligations for me to:
• Inform a potential victim of a client’s intention to harm them;
• Inform an appropriate family member, health care professional, or police if necessary of a client’s intention to end his or her life;
• Release a client’s file if there is a court order to do so;
• Inform the Children’s Aid Society if there is suspicion of a child at risk of harm or in need of protection due to neglect, or physical, sexual or emotional abuse;
• Report sexual abuse of a client by another regulated health professional;
• Report elder abuse of a resident in long-term care.
While these events are rare, they do exist. However, I aim to make this a place where you feel comfortable talking about personal concerns. I will also consult with other professionals for guidance specific to the therapeutic approach I use for the purpose of providing you with the highest quality care. Information provided in these other contexts will be anonymous.
Finally, in a situation of unexpected death or illness, you may be contacted by a representative acting on my behalf. This representative will be obliged to ensure confidentiality as the therapist does and will provide you with an appropriate referral.
Privacy and Record
Keeping Records are retained for at least ten years from the date of the last interaction with the client or for ten years from the client’s 18th birthday, whichever is later. All information is maintained in compliance with the Personal Information Protection and Electronic Documents Act (PIPEDA) of the Federal Government of Canada and the Personal Health Information and Protection Act (PHIPA) of the Province of Ontario. This means that all personal information obtained, used, and disclosed in therapy sessions is done so with your consent. Your personal information is protected by specific safeguards, including locked cabinets and computer passwords. You may request a copy of your records for a reasonable fee for the time spent preparing, copying and mailing the file (where applicable). Please note that records cannot be released when they contain the name of another person, and redaction of content is necessary to protect that person’s confidentiality, and reports from other professionals cannot be released without the consent of that professional.
Nature of the Relationship
The boundaries of a psychoanalytic relationship are important to understand at the outset. I can only be your analyst and cannot have any other role in your life, such as becoming a friend or socializing outside of session. In order to protect your confidentiality, I will not acknowledge you first should I recognize you out in public; however, you are welcome to say hello first if you wish. To preserve the therapeutic alliance, your therapist will not take you and another family member or loved one simultaneously on as individual clients. In certain cases, you may be interested in attending workshops and trainings that I lead, in which case, I may also be your teacher or facilitator. Should this be the case, we will discuss the pros and cons of attending one of these events, the difference in my role in that different setting, and whether or not this is the right fit for you at this time. When acting in these roles, I will never disclose the fact that you are also her client, although you are free to do so if you wish.
Payment Policy
Full payment is required at the time of each scheduled appointment in the form of cash, eTransfer or online credit card payment through PayPal or Quickbooks. You will receive an invoice prior to each session. If paying by eTransfer, payment must be received prior to the start of session. Any outstanding payment for sessions will be required prior to scheduling subsequent appointments.
Cancellations and Missed Sessions
Please email or text (if I have made my personal cell number available). You will receive an email reminder 36 hours prior to your appointment.
Cancellations within 36 hours from the session and missed sessions will be billed at the full rate.
If you cancel or miss three consecutive appointments or fail to respond to my attempts at contacting you, I reserve the right to discontinue your treatment, and you will be provided with information about other services that might be of assistance if this is of interest to you.
Cancellation or missed session fees will be waived on compassionate grounds, for example, in the event of sickness, a medical emergency requiring urgent professional treatment, or death in the family. In the case of bad weather or dangerous road conditions, sessions will still take place by phone or video call. Cancelling a session due to weather will follow the same cancellation policy as above.
Scheduling policy
Should you need to change your regular session time and day to find a new regular time to meet, four weeks’ notice is required to ensure I can accommodate your scheduling needs.
Termination of work
Should you wish to end our therapeutic relationship, you agree to meet to discuss the end of our work together and to give me four weeks’ notice prior to the end of our therapeutic relationship to allow for a supportive process for you.
In Case of Emergency
Emergency services are not available from me between sessions. In case of emergency, dial 911, go to the nearest emergency department of any hospital, or call your local crisis line.