Therapy – Self Referral Form

What is a Therapy Agreement? A Therapy Agreement is a contract between you and our company providing your care.  It clarifies issues of confidentiality, risk, accountability, attendance, fees, and cancellations.

Professional Accountability - Each Therapist on our team has a contract to provide services to patients on behalf of the company.  Thus the company is the service provider.

Each therapist under contract has evidenced their training and provided references prior to starting with this practice, and have undertaken a rigorous clinical interview to confirm they are working to a high professional standard.

Access to Therapy - Meeting a patient’s mental health needs is very important to us. However, there may be occasions where we determine that our service is not the most appropriate option for an individual’s care. In such circumstances, we will aim to recommend alternative services or support options where possible.

This decision may be made at the point of referral, following assessment, or after a period of therapy. It may also arise where a patient’s mental health needs or treatment requirements change over time, are more complex than initially outlined in the referral, or where funding arrangements have changed.

Access to therapy within our service is provided at the discretion of the service and the treating therapist. Clinical decisions are reviewed on an ongoing basis, and recommendations regarding suitability for treatment may change over time in line with clinical judgement and service capacity.

Personal Data - The company collects and stores your personal data in case there is a safety risk or a safeguarding concern. Clinical notes will be password protected, accessed only by those within this service, and stored for seven years under legal guidelines. For more information please read our GDPR Policy Document. 

Confidentiality & Privacy - Respecting your confidentiality is fundamental to our practice. Confidentiality of your clinical notes and therapy attendance are held within the team. Your Therapist has a duty of care that means that if they have concerns about your safety or that of a vulnerable adult or child, they will disclose limited information of this concern to your next of kin and other services (i.e. GP/ safeguarding team). The concern may also be discussed with other therapists within the team, as part of clinical supervision. Your Therapist will also disclose information if they are legally obliged, or if a serious crime has taken place, especially if others are still at risk (i.e. the perpetrator still has contact with vulnerable adults or children). Your Therapist will aim to discuss all safety concerns with you first, before disclosing information to others, although this is not always possible.

If someone else is paying for your sessions, or has provided card details to our system (i.e. a family member, friend or a third party) and they enquire about your attendance, we may provide limited information pertaining to which sessions have been attended/ missed.

It is agreed that neither party will record any of the sessions with any type of recording device unless written prior agreement of both parties has been given. For full information on confidentiality please read our Privacy Policy. 

Cancellation Policy - Please give your therapist at least 24 hours’ notice if you need to cancel or change an appointment by texting their mobile which is on your Confirmation Email. If an appointment is cancelled between 24 – 3 hours, we charge half fee. If cancelled under 3 hours or you do not attend, we will charge the full fee to the stored card connected to your profile. Payments outstanding more than 24 hours after the end of your session may incur a £5 admin fee.

Multiple cancelled appointments may mean it is not the right time for therapy, and we may recommended suspending treatment until regular attendance is possible.

Health Insurance Providers do not pay for missed or cancelled sessions. The outstanding fee will be charged to you the client, via any stored card, as per your Insurance Agreement.

In the case of any fee disputes, we may provide evidence to your bank of this signed therapy agreement. We may also disclose information to a third party (i.e. insurance) should any situations create an alert to use our policy.

Please note that VAT is chargeable where applicable.

Parent/ Carer - By completing this Therapy Agreement we assume you have legal parental responsibility (P.R.) for the above child / young person. We may request you attend one session (or more) alone with the therapist to provide background information and consider how to support the therapy process from a parent/carers perspective.

Clients over 13 years are able to provide their own consent and we are legally obliged to follows their wishes unless evidence suggests otherwise. 

Notes taken during a parent/ carer session will be stored under the child's profile. The child will be entitled to have access to their notes should they request them, in the future. Please alert your therapist if you want the clinical notes from  parent/carer sessions to be stored separately.