Hypnotherapy and Psycho-therapeutic counselling, REBT, and NLP Transformation Coach based in Marlow, Bucks.
For PDF downloadable file here.
Terms and Conditions of Practices
Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the National Hypnotherapy Society and the National Counselling Society, governing bodies of ethical framework to which to which I am a member. It provides privacy protections and patient rights about data protection and the legal guidelines for the purposes of treatment, payment, and duty of care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
- Psychological Services
Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in hypnotherapy, counselling, psychotherapy or talking therapies, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
1.1 Hypnotherapy has many benefits and zero side effects. Therapy works by tapping into the unconscious mind to instill the changes that you want. Risks may include apprehension about being out of control when under hypnosis. This is a myth often misunderstood by many clients. You are still in complete control under hypnosis. Therapy works by relaxing the body using your sensory modalities, the mind will automatically relax and you will become ‘suggestible’ to the changes you desire. Therapy can improve health and wellbeing through change of behaviour, habits, and increase satisfaction and motivation. Therapy can reduce anxiety, stress, and resolutions to specific problems. But, there are no guarantees about what will happen. Therapy requires a very active effort on your part to achieving your desired goals. In order to be most successful, you will have to work on things we discuss, outside of sessions as well as in sessions.
1.2 Psychotherapy, Counselling or any form of talking therapies has both benefits and risks. Risks may include experiencing uncomfortable feelings and emotions, such as sadness, guilt, anxiety, anger, frustration, loneliness, helplessness etc, because the process of therapy often requires discussing, exploring, reviewing, imagining, observing and recollecting the unpleasant aspects of your life. However, therapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Therapy requires a very active effort on your part to achieving your desired goals. In order to be most successful, you will have to work on things we discuss, outside of sessions as well as in sessions.
1.3 NLP Transformation Coach is a block of coaching sessions using NLP and Hypnotherapy techniques. Each block of session is specifically designed in the session according to the presenting problems. A coach session is designed to transform your life and increase your outcomes. The session has element of Time Line Therapy, Hypnotherapy and any other intervention that I feel is relevant to escalate clients to reach their full potential. Coach session is targeting to aspire client to think big and reach for the horizon and beyond. NLP techniques will be primarily used to bring smart goals to fruition. NLP is the model of change effective change. It bypass many psychological functions, focus on change of states using presuppositions.
The first 2-3 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions, diagnosis of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with me. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.
Therapy is a safe space for you to be opened and honest with your needs. Therapy is your time, for you to be yourself, to be who you want to be, to explore who you want to be and aspire to be the person you want to be. Therapy is about connecting all the dots to understanding your needs and wants; changing and directing your focus to reaching the desire goals; and aspiring for the happier future of your choice.
- Appointments & Cancellations
Appointments will ordinarily be 50 minutes in duration for counselling or talking therapy, preferably once a week or fortnightly, at a time we agree on, although some sessions may be more or less frequent as needed. Coaching session will be 90 minutes in duration, at all times. The time scheduled for your appointment is assigned to you and you alone.
2.1 If you need to cancel or reschedule a session, I ask that you provide me with 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24-hour notice, my policy is to collect the amount of your co-payment [unless we both agree that you were unable to attend due to circumstances beyond your control], thus, you will be responsible for the payment fee of the missed appointment. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. It is for your benefit to ensure that you are not late or missed appointment as this may delay progress to your desire goals. It is with your best interest that you attend the appointments as agreed.
- Professional fees
The standard fee for the initial intake of Hypnotherapy is £70.00. Each subsequent 50 minutes session is £60.00. Initial session will be a 90 minutes session.
The standard fee for the initial intake of Counselling, or Psychotherapy for a 50 minutes session is £50.00.
The standard fee for the initial intake of NLP Transformation Coach is £95.00. Each session will be a 90 minutes session.
Fees are non-negotiable. Fees are subject to change at my discretion but I will give you one month’s notice. In addition to weekly appointments, it is my practice to charge this amount on an hourly basis (I will break down the hourly cost) for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested.. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.
You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by Cash, Cheque, Paypal or BACS transfer; I am not able to process credit card charges as payment. Any Cheques returned to my office are subject to an additional fee of £25.00 administration. If you refuse to pay your debt, I reserve the right to use legal representation or collection agency to secure payment.
If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required. An invoice/Receipt of payment can be provided upon requests, please do not hesitate to speak to me in more details at any time during therapy.
- Session Duration
The initial session for Hypnotherapy will be 90 minutes, where I will be taking details case of your history, following by therapy of choice. Each subsequent sessions will be 50 minutes.
All Counselling or Psychotherapy will be 50 minutes. All Coaching sessions will be 90 minutes.
It is my responsibilities to other clients that session duration does not spill over the 50 minutes session, please respect the session etiquette & other visiting therapists and the time boundary.
It is It is your responsibilities to note down your appointment date/time and keep this information safe. It is part of the service that you take ownership of your responsibilities to keep to session appointment. It is part of therapy to promote empowerment and discipline to the session therapy.
- Insurance Claims
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for health treatment. With your permission, my billing service and I will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting me know if/when your coverage changes.
These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions.
If I am not a participating provider for your insurance plan, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement.
- Professional Record
I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location, only for the time of active therapy, after which they are destroyed by shredding. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file; this will be applicable to administration fee. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request; this will be applicable to administration fee.
I may keep records of your therapy sessions and a treatment plan which includes goals for your therapy for only up to 6 months, in case of recurring services. These records are kept to ensure a direction to your sessions and continuity in service. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Should you wish to have their records released, they are required to sign a release of information which specifies what information is to be released and to whom. Records will be destroyed and shredded after 6 months on the day of the last session date. Recurring clients after 6 months of therapy may be required to complete another notation record and evaluation. Review of your circumstance is required as your situation may have changed.
My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Consent to Treatment Consultation. You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.
This includes but is not exclusive to online services via Skype, telephone, email, text or chat. Due to the nature of online services, there is always the possibility that unauthorized persons may attempt to discover your personal information. I will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions with regard to authorized and unauthorized access to any technology used in therapy sessions. Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your therapy sessions. Should a client have concerns about the safety of their email, I can arrange to encrypt email communication with you, please request this writing.
As a rule, I will disclose no information about you, or the fact that you are my patient, without your written consent. My formal Private Practice Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports and assessments. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. However, I do not routinely disclose information in such circumstances, so I will require your permission in advance, either through your consent at the onset of our relationship (by signing the consent form), or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting me.
“Limits of Confidentiality”: Possible Uses and Disclosures of Records without Consent or Authorization
There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by my own choice, [some because of policies in the government office/agency], and some required by law. If you wish to receive services from me, you must sign the attached form indicating that you understand and accept my policies about confidentiality and its limits. We will discuss these issues now, but you may reopen the conversation at any time during our work together.
I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required:
- Emergency: If you are involved in in a life-threatening emergency and I cannot ask your permission, I will share information [to someone like the Paramedics] if I believe you would have wanted me to do so, or if I believe it will be helpful to you.
- Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by UK law to report the matter immediately to the Department of Social Services.
- Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by UK law to immediately make a report and provide relevant information to the Department of Welfare or Social Services.
- Health Oversight: the law requires that licensed private registered practitioners/therapist/counsellors/psychotherapist [social care workers] report misconduct by a health care provider of their own profession. By policy, I also reserve the right to report misconduct by health care providers of other professions. [For Counsellors: the law requires that licensed counsellors report misconduct by any mental health care provider.] By law, if you describe unprofessional conduct by another mental health provider of any profession, I am required to explain to you how to make such a report. If you are yourself a health care provider, I am required by law to report to your licensing board that you are in treatment with me if I believe your condition places the public at risk.
- Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged, and I will not release information unless you provide written authorization or a judge issues a court order. If I receive a notice for records or testimony, I will notify you so you can become aware and give authority to approve or disprove. However, while awaiting the judge’s decision, I am required to place said records in a sealed envelope and provide them to the Clerk of Court. In civil court cases, therapy information is not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in any case in which the judge deems the information to be “necessary for the proper administration of justice.” In criminal cases, the law has no statute granting therapist-patient privilege, although records can sometimes be protected on another basis. Protections of privilege may not apply if I do an evaluation for a third party or where the evaluation is court- ordered. You will be informed in advance if this is the case.
. Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
“Patient’s Rights and Provider’s Duties.” Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission. Knowing your rights, please read this section carefully.
- Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.
- Right to Receive Confidential Communications by Alternative Means and at Alternative Locations — You have the right to request and receive confidential communications of Personal Health Information [your personal health record taken at the initial consultation] by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address. You may also request that I contact you only at work, or that I do not leave voice mail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
- Right to an Accounting of Disclosures – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization. On your written request, I will discuss with you the details of the accounting payment records.
- Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge an administration fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain therapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding.
- Right to Amend – If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted dot me. In addition, you must provide a reason that supports s your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.
- Right to a copy of this notice – You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. Changes to this notice: I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information I already have about you as well as any information I receive in the future. The notice will contain the effective date. A new copy will be given to you or posted in the waiting room. I will have copies of the current notice available on request.
Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the governing bodies which I am a member.
- Parents & Minors
While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 18. For children 16 and older, who has strong preference to private therapy will need to be accompanied by a parent.
As a general rule, I have a duty of care to minors and parents who seek my services, it is possible that I would recommend another health professional or therapist near you.
- Contacting me
I am often not immediately available by telephone on 07976 355 705. This is the best number to contact me. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take 24 hours for non-urgent matters. If, for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) contact c/o Springwell Clinic, 10 – 12 Oxford Road, Marlow, Bucks, SL7 2NL (01628 308060), 2) go to your Local GP, or 3) call 111 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering my practice.
I may request client’s email address. Client has the right to refuse to divulge email address. I may use email addresses to periodically check in with clients who have ended therapy suddenly. I may also use email addresses to send future newsletters with valuable therapeutic information such as tips for depression or relaxation techniques. I may also have a blog and if this is appropriate for the client, I may send information through email about subscribing to the blog or information related to mental health and wellness.
If you would like to receive any correspondence through email, please write your email address here _________________________________________.
If blank I would assumed that you like to opt out of future email correspondence.
- Other Rights & Boundaries
During therapy; if you are unhappy with what is happening in therapy, I hope you will discuss with me so that I can respond to your concerns. I hope to address any issues sensitively. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or intimate relationships with clients or with former clients. You have the right to expect that I will not have media social contact with clients or with former clients on any social networking websites. You have the right to expect that I will not engage with you, unless you initiated the encounter outside of therapy, and if you acknowledge the encounter, you have the right to expect that I will not engage with you about therapy. You have the right to expect that I will not call/visit you for any form of social event. Should we meet at event social event, you have the right to expect that I will not engage with you.
During therapy: you have the right to expect that I will not engage or interact with you using social media sites for personal nature. You may be able to follow me on social media sites (Facebook, LinkedIn, Twitter etc) for news, blogs, my latest articles on services at Patchouli Therapy, but please be aware that I may not follow your or accept you as friend for personal nature. Please note that this is for ethical boundaries and it is not a personal rejection.
Contract Consent to Services
Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms and I consent to accept these policies as a condition of receiving therapy.
Signature of Patient or Personal Representative
Printed Name of Patient or Personal Representative
Description of Personal Representative’s Authority:
Consent to Treatment Consultation
I wish to receive consultation services from Patch Welling of Patchouli Therapy.
I understand that these consultations do/not constitute supervision and that I remain completely responsible – ethically and legally – for the decisions I make in my own case situations. My consultant will provide me with an opportunity to discuss cases and issues about which s/he may have some expertise, and s/he may help me consider options for responding, but the comments made for my consideration are not super visional mandates.
I also understand that although we may sometimes need to discuss personal issues that may be relevant to my treatment work, I remain completely responsible – ethically and legally – for what I disclosed and the participation in my own case situations.
I understand that prior to seeking consultation services, I have been recommended to discuss with my General Practitioner before commencing treatment. My doctor name and address details are: ________________________________________
I understand the potential limits of the confidentiality of this relationship. To the extent possible, my case presentations will provide no identifiable patient information. However, I understand that if I provide identifiable information about a situation regarding which my consultant has an ethical or legal obligation to report confidential information, s/he will inform me at the time and will give me the opportunity to make the report myself. I understand that where some identifiable information is kept, they are confidentially kept safe and securely locked.
I understand that if my consultant becomes aware that s/he knows or has a prior relationship with the presented client(s), or if she believes she has a potential conflict of interest in her relationship with me, she will notify me of that fact immediately and will cooperate in helping me find a different consultant.
I agree to the fee per consultation session, payable at each meeting.
(Name of Client — please print)
Agreement for Confidentiality of Treatment
I understand that it is the therapist’s role to provide therapeutic services so that I might feel better and/or improve my functioning, especially as it relates to my family. The therapist’s role is not intended to gather information for the courts or to make judgments related to my family.
Therefore, I agree that I will not call upon the therapist to provide treatment records or to testify in a future divorce or custody action. I understand that courts can appoint professionals who have had no prior contact with my family to conduct independent evaluations and make recommendations to the court.
I understand that it is the therapist’s policy to have no court involvement in my case because that could harm our professional relationship and the ability to achieve my goals. My goals include resolving personal concerns so that I might preserve my marriage and/or be a better parent. Since I need to speak freely, my spouse is also agreeing never to ask the therapist to testify or have his records of my treatment in court.
By signing this form we are both agreeing not to use any of my therapeutic intervention records or testimony in any future court proceedings.