The following document will be discussed during the initial session; please take the time to review it and note any questions or concerns you may have, so we may properly address them.

INFORMED CONSENT

Welcome to my practice.

I am Lora Dikova-Bradford, a Registered Psychotherapist (RP) with the College of Registered Psychotherapists of Ontario (CRPO), registration number 003717. I practice in accordance with the CRPO’s Standards of Practice and Code of Ethics. You may verify my registration status at any time through the CRPO public register at www.crpo.ca.

In this document, I will provide you with information about my professional qualifications and approach to treatment, as well as the benefits and risks of psychotherapy, client rights and responsibilities, confidentiality, and payment policies, so that you may make an informed decision about your participation. I am glad to answer any questions or concerns you may have.

Psychotherapy is intended to help individuals and couples improve their sense of well-being and resolve issues adversely affecting the quality of their lives. This primarily talk-based therapy has been shown to benefit those who engage in it, often leading to better relationships, solutions to specific problems, reduced distress, improved self-esteem, and an enhanced overall sense of functioning. It is important to note that psychotherapy is a personal exploration, and there are no guarantees of what you may or may not experience — your outcomes are largely related to your efforts and participation. Since therapy often involves discussing unpleasant aspects of life, it is not unusual to experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, or helplessness. If this occurs, please talk to me so I can adequately support you. I believe clients have the capacity and resilience to resolve their own problems and make their own decisions; however, from time to time we all need assistance, support, and direction, and I will work with you to establish goals and map out the steps of your therapy.

I am trained and experienced in evidence-based psycho-social interventions for individuals and couples struggling with relationship issues, depression, stress, anxiety, and post-traumatic stress. I have supported clients from diverse populations in various ways — from alleviating everyday stress and anxiety to managing mood, behaviour, and personality disorders. To meet each client’s individual needs, I use an integrative approach, drawing from models such as Cognitive-Behavioural Therapy (CBT), Psychodynamic Therapy, the Developmental Model of Couples Therapy, Emotionally Focused Couples Therapy, Dialectical Behavioural Therapy, Motivational Interviewing, and Trauma-Informed Treatment Methods.

CONFIDENTIALITY

As your counsellor, I am committed to protecting your right to confidentiality; information shared during our sessions will not be revealed to any other agency without your written permission or request.

There are certain situations in which I may be legally required to reveal information obtained during counselling to a third party without your consent, including when:

• I have reason to suspect a child may need protection (e.g., abuse or neglect) — there is a legal obligation to inform the Children’s Aid Society if a client is placing a child at risk of sexual or physical abuse.

• I recognize that you may pose a danger to yourself and/or others (e.g., suicidal ideation, exposure or transmission of infectious disease, or plans that may endanger the life, health, or security of others).

• Counselling records are ordered to be produced by a court of law.

• I must use information from your record to defend myself in a professional liability lawsuit filed by you.

• The client is a health professional who is abusing or has sexually abused a client/patient — this must be reported to their regulatory body.

• In a medical, psychiatric, or psychological emergency, I will contact your identified emergency contact and/or the appropriate emergency response services.

Confidentiality and shared records: When an individual participates in group, family, or couple therapy and requests access to the record, I can only provide information relating to the individual who filed the request, unless other participants have provided consent.

To ensure quality of service and as part of my commitment to professional development, I engage in regular clinical supervision.

Consent for supervision: In the event that your therapist requires supervision by Dr. Bita, Clinical Psychologist, CPO#5333, for training purposes, you consent for your therapist to be supervised by Dr. Bita, which involves some degree of disclosure. You understand that you may request a meeting with Dr. Bita if you wish; she can be reached at director@clinicdrbita.com. Information shared with your therapist, including reports, evaluations, assessments, and tests, will remain confidential and will not be disclosed to anyone — except as needed with Dr. Bita — without your explicit written consent, unless one of the following arises: risk of harm to you, your child, or another individual; a subpoena or court order demanding disclosure; or evidence that the safety or development of a child or vulnerable adult has been or is at risk of abuse.

COUNSELLING RELATIONSHIP

It is helpful to remember that our relationship is professional, not social. This professional relationship is the foundation of psychotherapy and is central to the provision of safe, effective and ethical care.

CLIENT RIGHTS AND RESPONSIBILITIES

• You are responsible for arriving on time and not being under the influence of drugs or alcohol during sessions.

• You are responsible for paying the agreed-upon fees.

• You have the right to participate in developing an individual treatment plan outlining your goals and the specific objectives you will work on.

• You have the right to an explanation of services in accordance with your treatment plan.

• You have the right to participate voluntarily in, and consent to, treatment.

• You have the right to be treated ethically and free from abuse, discrimination, mistreatment, or exploitation.

• You have the right to object to or terminate treatment at any time, though I ask that you participate in a termination session.

• Your consent to participate in psychotherapy is ongoing and may be withdrawn at any time, for any reason, without penalty. Withdrawing consent means you may pause or discontinue treatment; it does not affect your right to access emergency or crisis services, nor does it affect fees already incurred for services provided prior to withdrawal. If you are dissatisfied with my services, please let me know. If I cannot resolve your concerns, you may contact the College of Registered Psychotherapists of Ontario to file a complaint. The CRPO can be contacted by mail at 375 University Avenue, Suite 800, Toronto, ON M5G 2J5; by telephone at 416-479-4330; toll-free at 1-844-712-1364; or by email at info@crpo.ca.

TELEHEALTH SERVICES (CLINIKO)