Cyclic Wisdom Consent Form (Individual Sessions)

This document is to inform you about what you can expect from me and from our work together and to give you the opportunity to give consent to proceed with this process. I’m happy to discuss any questions you may have before or during the time we work together.

About my Professional Orientation:

I have a transpersonal approach to inner work mainly focused on trauma recovery that weaves, within others, tools such as dance/movement & somatic psychotherapy, EMDR, cyclical awareness, conscious embodiment & breathing practices, self-inquiry, psycho-spiritual education, within others. My approach continues to develop as I deepen my own spiritual journey & professional practice in areas of transpersonal therapy, trauma, somatic & body/movement practices, EMDR, collective & ancestral legacies of trauma, social justice, yoga and other practices of consciousness development.

EMDR:

EMDR is a treatment approach that has been widely validated by research for the treatment of PTSD. Research on other applications is now in progress. Distressing, unresolved memories may surface through out the EMDR procedure, and subsequent to the treatment session, the processing of incidents/material may continue and other dreams, memories, flashbacks, feelings, etc., may surface. If I consider EMDR can be useful for your treatment, I will communicate it to you and explain the procedure in detail so that you can choose whether you would like me to use it.

Session length:

The sessions are 50 to 60 min per appointment unless otherwise arranged.

Current Fee:

Our first session will be 75min with a fee of $175. After that, my current fee is between CAD$160 - $180 per session including GST, unless otherwise arranged. You can pay each session by making an e-transfer to veronica@cyclicwisdom.com. I will provide a receipt for the clinical services provided, acknowledging payment. Please select your fee:

Cancellation Policy

When we schedule a session, I reserve that time & space for our work together. I kindly ask you to give me a minimum of 24 hours of notice when you need to cancel, otherwise I will charge for the missed session. Thank you for understanding.

Preparing for Sessions:

• Before each session, I invite you to take the time to bring consciousness into what has happened in between sessions, what you have been working on and to meditate on your intention for the session. • I recommend you have a journal for your journey where you can record important info. • After each session, I suggest you take some quality me time to integrate your experience. • I use Zoom for online sessions. I will send you the link before our session. • Organize the space where you will have the session: silent, private, comfortable. • Make sure you have good internet connection to allow as much flow as possible. • Make sure you have a good internet connection to allow as much flow as possible for the session.

Confidentiality:

Everything that transpires between us is confidential. Confidentiality continues after the end of the therapy relationship. There are exceptions as prescribed by law. In particular these are: - If a child is or may be at risk of abuse or neglect or in need of protection. - If I believe that you or another person is at clear risk of imminent harm. - For the purpose of complying with a legal order such as a subpoena, or if the disclosure is otherwise required or authorized bylaw. I may disclose information for the purpose of a professional consultation, in which case your identity will remain confidential. If you have any questions or concerns about how B.C.’s Personal Information Protection Act or how a counsellor’s personal information policies and procedures apply, please ask.

Extended Benefits Coverage:

I am a Registered Clinical Counsellor with the British Columbia Association of Clinical Counselling (BCACC); my membership number is #16823. You can inquire with your benefits administrator to determine if my services can be covered, the scope of coverage and to seek reimbursement for the cost of the sessions.

Reviews, referrals and ending:

In treatment, it is your right at any time to: - Have a review of your progress and of any of the topics in this form; - Be provided with a referral to another counsellor or health professional; - Withdraw consent for the collection or disclosure of your personal information, except where precluded by law; - End the counselling relationship by so advising me; - Access or obtain a copy of the information in your counselling records, subject to legal requirements. Your right of access to or to obtain a copy of your personal information continues after the end of the counselling relationship.

Ending treatment:

I advocate for every individual’s right to choose what treatment best serves their healing and highest good. When you feel it is time to move on, I invite you to discuss this with me so that we may review your journey and you may have a supportive closure to our work together. I will also discuss with you if I feel it is time for you to move on, but you are free to continue with the sessions if you do not feel ready, or to stop and come back at a later time

Concerns:

If you have a concern about any aspect of your treatment, please do first address it with me. If this is impossible or unsafe, or if your concern is not resolved through discussion, you may contact the Registrar of the BC Association of Clinical Counsellors at 1-800-909-6303.

Disclaimer:

Nowhere in this contract for my services is there a “guarantee of cure or outcome.”

Signature

Submitting this form confirms that you have read the above, had an opportunity to discuss it with me, and had your questions answered to your satisfaction.

Name

First Name

Last Name

Pronouns

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Thank you for the time and care that you put into going through this information.

Welcome! I look forward to working with you :)

Veronica -