Christina Schmolke
Registered Psychologist
780-239-3344
Informed Consent Agreement________________________________________________________
Client Name:_______________________________________ Date:______________________
Welcome to my counselling practice. This document is intended to provide you
some answers about what to expect when you engage in counselling.
My Background and Approach. I am a registered psychologist with over 10 years of
experience in the human services. I am trained and experienced in providing
services to adults in individual and group formats. Early in my career, I worked in
the areas of suicide prevention and crisis intervention. I have also worked in
hospital and outpatient settings with individuals with addiction and mental health
concerns.
I hold the following qualifications:
o Registered psychologist with the College of Alberta Psychologists
o I completed a Master Degree in Counselling from the Graduate Centre for
Applied Psychology (Athabasca University)
o I am a member of the Psychological Association and Alberta and the
Canadian Psychotherapy and Counselling Association
o I am a Certified Sex Addiction Therapist Candidate
In my work with clients, I come from a strength-based approach. I believe that
clients are very capable but often lose touch with their sources of strength in
challenging times. I also draw from the following approaches: narrative therapy,
social justice paradigms, interpersonal neurobiology, solution-focused counselling,
motivational interviewing, and cognitive therapy. I ground my work with you in
interventions that have research support.
What to Expect From Our Relationship. As a psychologist, I am bound by legal and
ethical codes to safeguard your information. You can trust that what you tell me will
be kept safe, except for certain situations that will be explained. Because I have
engaged with you in a therapeutic setting, I cannot have any other role in your life.
This includes a friendship, supervisory relationship, business partnership, or a
sexual relationship.
If I receive any request to provide information about you, I will not release any
information, including if you are my client, without your written permission.
However, in certain situations required by law, I may have to disclose your
information without your consent.
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Christina Schmolke
Registered Psychologist
780-239-3344
Informed Consent Agreement________________________________________________________
Your records will be stored for at least 10 years, as determined by the College of
Alberta Psychologist standards. They will be kept in a safe place.
Benefits and Risks of Therapy. With any treatment, there are risks. There is a risk
that clients may experience uncomfortable emotions such as anxiety, sadness, anger,
or guilt. Clients may recall unpleasant memories, especially when they are no longer
engaging in addictive behaviour. When people pursue recovery from an addiction, it
is not uncommon to experience unpleasant emotions that the addictive behaviour
was masking. In addition, people from your community may view you negatively for
seeking counselling. People in counselling find that it often changes their
relationships to the people closest to them. For example, they may have difficulty
tolerating certain behaviours, such as secret keeping. Finally, there is a risk that
therapy may not be a good fit for you.
The positive effects of counselling have been well-supported by hundreds of
research studies. Clients who have problems with their mental health may find that
their mood improves. In addition, my clients have reported improvements in their
relationships with others, their work, their spirituality, and their ability to enjoy
their lives.
If for some reason therapy is not going well, we will discuss other options that may
include another healthcare provider.
Use of Technology. The use of technology such as cell phones and email augments
the risk to client confidentiality. Some of these risks may include:
o The possibility that messages may not be received
o Messages sent may be misinterpreted
o Messages sent via email may be permanently recorded on certain servers
o Confidentiality may be breached by unauthorized monitoring / interception
messages sent
o Email messages are not encrypted, meaning that they may be vulnerable to
hacking
Please be aware of the above risks if you wish to participate in telephone therapy.
Confidentiality. Confidentiality is the foundation of the client-counsellor
relationship. I am ethically and legally obligated to safeguard client information and
the manner in which I collect, use, and share information. Your information is
protected by the Freedom of Information and Protection of Privacy Act in Alberta.
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Christina Schmolke
Registered Psychologist
780-239-3344
Informed Consent Agreement________________________________________________________
You have the right to decide how much of your personal information can be given to
others. Your information will only be shared with others with your written
permission. You also have the right to view your information on your file.
The types of information typically collected in individual counselling include: case
notes, assessments, and treatment plans.
There are a few situations where your information can be shared with others
without your consent. These include:
o When urgent circumstances require the release of confidential information to
ensure your safety and the safety of others
o When information is subpoenaed for court proceedings
o When the law requires release, usually in circumstances where a child or
vulnerable adult is in need of protection or to investigate a death
When information is shared without your consent, a notice of disclosure will be
mailed to your last known address.
For more information on these policies, please contact the Office of the Information
and Privacy Commissioner for Alberta at 1-888-878-4044 (toll-free).
Working with Minors. I mostly work with adults. However, if a circumstance arises
where I see someone under the age of 18 for counselling, it may be necessary to
obtain permission from the minor’s caregivers prior to treatment.
Appointments. I am available to work with you regularly at scheduled times. Please
let me know if you are interested in this and we can set up future dates.
The first time I meet with you, we will need to give each other much basic
information. For this reason, I usually schedule 1.5-2 hours for our first meeting.
Following this, we will meet for 50 minutes per session. Most clients begin with
weekly sessions and gradually taper off to less frequent sessions.
Meetings with my clients are scheduled and we both agree to be on time. If an
unforeseeable circumstance arises, I ask for your understanding and assure you the
full time that you are owed.
Please try not to miss sessions if you can help it. A cancelled appointment delays our
work. When you must cancel, please give me at least 24 hours notice so I can try to
fill that appointment. If you are unable to provide 24 hours notice, you will be
charged the full fee for your session unless I am able to fill it. However, if you
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Christina Schmolke
Registered Psychologist
780-239-3344
Informed Consent Agreement________________________________________________________
reschedule your missed appointment within the week, the charge will be waived.
Fees, Payments, and Billing. Payment for services is an important part of any
professional relationship. You are responsible for seeing that my services are paid in
full at the beginning of session. Meeting this responsibility shows your commitment
and maturity.
Your fees may be paid by cash, debt, personal cheque, or credit card. Because I
expect full payment at the beginning of the session, I usually do not send bills.
However, I will provide you with a receipt which you can use to submit for
insurance coverage. If we agree that I will bill you, I require that bills be paid within
five days of when you receive it.
Participation in counselling requires a substantial amount of money, time, and
effort. In order for you to get the best value for your money, we must work hard and
well together.
If you think you may have trouble paying your fees on time, please discuss this with
me. If this occurs, I will also raise the situation with you to try and find a solution. If
your bill remains unpaid for an excessive amount of time, I am required to stop
therapy with you. Fees that continue to remain unpaid after this time will be
submitted to a collection agency.
Individual therapy services:
Assessment package for problematic sexual behaviour - $350
(this includes review of two assessments during a 1.5 hour session)
1.5 hour sessions - $200
50 minute sessions - $140
30 minute sessions - $90
Please note that the Psychologists Association of Alberta fee structure for individual
counselling is $170.00 per hour.
Extended sessions: Occasionally, it may be better to go on with a session rather than
stop or postpone it. In these situations, I will consult with you if the extension goes
longer than 10 minutes. For each 10 minutes that the session is extended, there will
be a $15 fee.
Telephone consultations / appointments: If I believe that telephone consultations
may be suitable or necessary, I will charge you our regular fee, prorated over the
time needed. If I have a telephone conversation that extends beyond 10 minutes
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Christina Schmolke
Registered Psychologist
780-239-3344
Informed Consent Agreement________________________________________________________
with other professionals as part of your treatment, you will be billed for these at the
same rate of our therapy services. If you are concerned with this policy, please
discuss it with me so we can set a policy that is comfortable for the both of us.
Reports. $150 per hour. I will bill you for any long or complex reports /
correspondence that you might require. It is unlikely that your insurance company
will reimburse you for this fee.
Contacting Myself. I will return phone messages within 24 hours except on certain
occasions. You can leave a voicemail and I will return your call as soon as I can. I do
not provide crisis counselling cannot promise you that I will be available at all
times. If you are in an emergency or crisis, I encourage you to leave a message on
my voicemail. However, if you need immediate support, you or your family
members should also call one of the following resources:
o 911
o Adult Mental Health Crisis Response Team: 780-342-7777
o Edmonton Distress Line: 780-482-4357
Divorce and Custody Disputes. If you ever become involved in a divorce or custody
dispute, I will not provide evaluations or expert testimony in court. You need to hire
a different mental health professional for this purpose. As your counsellor, my
statements may be seen as biased and any reports I may provide could negatively
affect our professional relationship. By signing this document, you are in agreement
with this matter.
Complaint Procedures. If you believe that I or any other therapist has treated you
unfairly or broken a rule, please let me know. You can also contact the College of
Alberta Psychologists:
The College of Alberta Psychologists
2100 SunLife Place
10123 - 99 Street
Edmonton AB T5J 3H1
Phone: 424-5070 (Edmonton)
1-800-659-0857 (Outside Edmonton)
e-mail: psych@cap.ab.ca
website: www.cap.ab.ca
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Christina Schmolke
Registered Psychologist
780-239-3344
Informed Consent Agreement________________________________________________________
Our Agreement
I, the client, have read, or have had read to me, and fully understand my rights and
responsibilities detailed in this document. My signature below indicates that I have
discussed those points I did not understand and if I had any questions, they were
fully answered. It is also my understanding that any of these points can be open to
change.
o I will abide by and act in accordance with the points covered in this
document.
o I understand the conditions by which Christina Schmolke, registered
psychologist, may waive confidentiality.
o I understand that I have the right to terminate therapy at any time.
__________________________________________ Date:__________________________________
Client signature
__________________________________________
Printed name
I, Christina Schmolke, have met with the client / guardian for a suitable period of
time and have informed him/her of the issues raised in this document. To the best of
my ability, I have answered any questions. I believe this person fully understands
each of the points raised in this document and I believe this person to be fully
competent and legally authorized to provide consent for treatment. I agree to enter
into therapy with this client as shown by my signature here:
__________________________________________ Date:__________________________________
Signature of counsellor
___Copy accepted by client / guardian ___Copy kept by therapist
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