CONSENT FOR PSYCHOTHERAPEUTIC TREATMENT SERVICES

Thank you for choosing Unleash Synergy and congratulations on taking this important step toward change! We kindly ask that you carefully review this vital document, as it provides essential details about our professional services and policies. Please kindly read through and confirm your review of this information by checking the checkbox at the end of this document.

INFORMATION AND CONSENT – COUNSELLING & PSYCHOTHERAPY

Generally, there is not an accepted distinction between counselling and psychotherapy. Some may suggest there are differences, while others may not. The terms are used interchangeably in this document. In the Psychotherapy Act (Ontario, 2007), psychotherapy is described as, “the assessment and treatment of cognitive, emotional or behavioral disturbances by psychotherapeutic means…” The Canadian Counselling and Psychotherapy Association describes counselling as, “the skilled and principled use of relationship to facilitate self-knowledge, emotional acceptance and growth and the optimal development of personal resources.” Your Registered Psychotherapist will discuss your specific treatment plan with you based on your unique need challenges, and wishes from psychotherapy/ counselling sessions, as well as their credentials and their supervised status.

THERAPEUTIC RELATIONSHIP

The therapeutic relationship is unique in that it combines highly personal elements with a contractual agreement. Therefore, it is crucial for us to establish a clear understanding of how our relationship will function and what each of us can anticipate. This consent form will establish a structured framework for our collaborative work. Please feel free to discuss any aspect of this with your psychotherapist/counsellor.

THE THERAPEUTIC PROCESS

Your decision to seek therapy reflects a positive step toward self-improvement. Psychotherapy and/or counseling represent a joint effort between you and your psychotherapist/counsellor. Your active engagement in the therapeutic process (coming on time, asking clarification questions, and doing ‘homework’) is essential for achieving positive results. While there are potential risks involved, such as the possibility of encountering uncomfortable emotions like sadness, guilt, anger, and frustration when discussing personal challenges, psychotherapy/counseling also offers numerous benefits.

These may include improved interpersonal relationships, enhanced self-esteem, better problem-solving skills, finding solutions to specific issues, reduction in overall distress, as well as working through relational/intimacy-related issues. There are no instant solutions, and we cannot guarantee changes in your behavior or circumstances. However, we assure you of our support and commitment to understanding your concerns and recurring patterns, as well as assisting you in clarifying your personal goals. Participation in psychotherapeutic treatment is entirely voluntary, and you have the autonomy to discontinue treatment at any point.

CONFIDENTIALITY

Your sharing in this setting is confidential. All session content and relevant materials related to your treatment will be held in strict confidence unless you request in writing to disclose all or part of this information to specific individuals. In keeping with ethical standards of the College of Psychologists of Ontario and provincial and federal privacy policies, we are committed to respecting and protecting your privacy. However, your confidentiality is limited by legal requirements of our profession.

There are specific limitations to the confidentiality privilege, which include:

• In situations where there is an immediate risk of harm to yourself or another person, your therapist is obligated by law to take steps to ensure safety by informing relevant individuals.
• If you disclose information regarding child or elder abuse, your therapist is legally required to report it to the appropriate authorities.
• If you disclose information about assault or abuse by a healthcare professional, your therapist is obligated by law to report this to the authorities.
• If your therapist receives a court order for your clinical records or testimony, they will endeavor to discuss it thoroughly with you before taking any action, as such situations are rare.
• Occasionally, we may need to consult with other professionals to ensure the most effective treatment for you, in such cases, information about you may be shared with a supervisor without disclosing your name.

If you happen to encounter your therapist accidentally outside the therapy setting, your psychotherapist/counsellor will refrain from initiating acknowledgment out of respect for your privacy and confidentiality. However, if you initiate contact, they will be happy to briefly engage with you while maintaining discretion and avoiding extended discussions in public or outside the therapy environment.

COUNSELLING NOTES

The records may include items such as personal information, progress notes, and evaluations, and will be shredded, electronically deleted 7 years after your file has been closed. No information about you can be released to a third party without your prior written consent, or verbal consent in the case of an emergency.

Evguenia Cheinis, Registered Psychotherapist keeps counselling notes during sessions so that it is possible to keep a record of your preferred words/language, the issues discussed, and ideas that have been developed in the counselling. These notes are secured in a locked filing cabinet, or password protected electronically, or stored on Acuity and they are considered confidential. Your counsellor keeps progress notes from the beginning to the end of your counselling experience. These are kept electronically, are secured and confidential, and a maintained according to current health and privacy legislation.

FEEDBACK & EVALUATION

Your Registered Psychotherapist is committed to responding to your evaluation of the psychotherapy/counselling service you receive, she provides a number of ways to invite your feedback:

During counselling, your Registered Psychotherapist will ask you about how the conversations are going. In this way, you will have the opportunity to inform the direction of the counselling. Your Registered Psychotherapist may also give you various evaluations/questionnaires to complete, regarding your experience of the service you’ve received, as well as related to your symptoms. Your Registered Psychotherapist will discuss this with you as applicable, and it is entirely up to you whether you fill this out.

You may also choose to provide feedback to your counsellor at any time. Your Registered Psychotherapist welcomes positive feedback as well as constructive feedback for improvements. All feedback that we receive is taken seriously and is appreciated. Complaints or concerns can be made directly to Evguenia Cheinis, Registered Psychotherapist.

ONLINE/ TELETHERAPY CONSENT

Confidentiality will be ensured on the Registered Psychotherapist end via a private room for the session. The client assumes responsibility for ensuring the privacy of the space that they receive therapy in. It is recommended that clients choose an environment for receiving services that is comfortable, free from distraction and potential disruption. Therapeutic treatments of all kinds have been found to be effective in treating a wide range of mental health concerns, though there is no guarantee that all treatments will be effective. While you may benefit from teletherapy, this benefit cannot be assured. Teletherapy is different from in person therapy; if you or your Registered Psychotherapist believes that you would be better served by another form of psychotherapeutic service (such as in person treatment), you may seek or be referred to another therapist that can provide service in your region.

EMAIL & SERVICES OVER THE INTERNET, SECURITY

Evguenia Cheinis, Registered Psychotherapist, may communicate with you via email. Efforts will be made to limit health information shared through email and text. You may opt out by informing your therapist. By consenting to email or text communication, you accept the risk that these exchanges may not be fully secure. If you share detailed personal or health information, this implies consent to similar responses from your therapist.

Your therapist may occasionally send mass emails about practice updates, new services, or wellness tips. You can opt out by notifying your therapist or unsubscribing. Virtual sessions (phone/video) are available. By participating, you acknowledge the inherent security risks of internet-based communication. Your therapist will take reasonable steps to ensure privacy. For more details, contact your therapist.

For example, emails with information about changes in practice, noting information about new services offered stress management tips, etc. You may choose not to receive these communications by notifying your Registered Psychotherapist, or by unsubscribing electronically.

LICENSURE AND EXTENDED BENEFIT COVERAGE

Evguenia is a Registered Psychotherapist and an active member of the College of Registered Psychotherapists of Ontario (CRPO) with a Master of Arts in Counselling Psychology degree from Yorkville University. She also holds a B. Des. from York University, a Brennan Healing Professional Studies Diploma from the World’s Premier Hands-on Healing program (Barbara Brennan School of Healing), as well as an Intensive Sex Therapy Training Program Certificate from the University of Guelph. Evguenia is also receiving professional supervision in couples and sex therapy, further enhancing her qualifications and ensuring the highest standard of care for her clients.

It’s important to note that while not all therapists are covered by insurance plans, some plans may offer a Health Care Spending Account that can be used to cover therapy costs. We will assist in processing your claim, but ultimately, it’s your responsibility to seek reimbursement. If therapy services are not covered by your benefits or you don’t have extended benefits, you may still be able to claim therapy costs on your income taxes. For more information, please consult with your therapist.

SESSION PAYMENTS

The fee for each 50-minute session is $175 for individual sessions and $200 for couple and relationship sessions. Evguenia also offers reduced rates—please reach out to discuss what is feasible for your budget. She will be happy to explore available options, as we prioritize your care.

Payment is due at the time of the session and can be made via email money transfer or credit card (VISA, Mastercard, or AMEX). To streamline payment processing, we use Stripe and Acuity to securely process and store credit card information. If paying by credit card, please provide your card number, expiration date, and CVC (3-digit code on the back) to keep on file for automatic payments.

Our office will process payments within one business day following your session. If you choose to pay by e-transfer, the full amount must be sent at the time of the session—especially if you have a credit card on file—to avoid duplicate charges. Account balances older than 30 days may be reported to the credit bureau. We will send friendly reminders before taking this step, so please contact us as soon as possible to avoid this process.

EMERGENCIES

You may experience an emotional crisis which requires immediate attention. You should contact your family physician or go to the emergency department of the nearest hospital, as Evguenia Cheinis, Registered Psychotherapist is not a crisis service.

CANCELLATION POLICY

If you need to reschedule the date or time of your appointment, please contact Evguenia by email at least 48 hours before the scheduled appointment. With sufficient notice, we can accommodate your request for a new appointment time. Additionally, this allows us to offer the previously reserved time slot to another client. We understand that unforeseen emergencies may arise, and we appreciate being notified as soon as possible if you’re unable to keep your appointment. We extend the same courtesy to you if your therapist ever needs to reschedule due to an emergency on their end.

In the event of a missed appointment without prior notice of at least 48 hours, or for non-emergency reasons, you will be invoiced for the session (equivalent to the full session fee). It’s important to note that insurance providers typically do not cover the costs associated with missed appointments.

MUTUAL RIGHTS AND RESPONSIBILITIES

The relationship must remain limited to a respectful therapeutic framework. You may refuse any therapeutic suggestions offered to you, or to suspend or cease treatment at any time. If you decide to stop treatment for a reason, please notify Evguenia Cheinis, Registered Psychotherapist so that your file can be closed and/you can be referred to another resource.

SOCIAL MEDIA POLICY

Friending & Following
To maintain confidentiality and professional boundaries, Evguenia does not accept friend or contact requests from clients on social media. Clients may follow her professional content but should consider privacy implications. She does not follow clients to preserve therapeutic boundaries; relevant online content can be shared in sessions.

Interacting
Clients should avoid texting or messaging via social media, as these are not secure. Public interactions, such as comments or tags, should also be avoided. For communication outside sessions, phone calls are preferred, with email used only for scheduling.

Searches & Location Tracking
Evguenia does not search for clients online, except in rare crises where safety is a concern. Clients using location-based apps should be aware their visits may be inferred by others.

Email
Email should be limited to scheduling, as it is not fully secure. All email exchanges become part of the client’s record. Concerns about this policy can be discussed in sessions.

ZOOM AI USAGE

Evguenia Cheinis, RP, utilizes Zoom AI, a secure, HIPAA-compliant platform that incorporates artificial intelligence to assist in generating clinical notes and insights from therapy sessions. This technology is intended to enhance the quality of care provided. All notes and insights generated are confidential and safeguarded by strict privacy and security measures.

Evguenia Cheinis has a Business Associate Agreement (BAA) with Zoom Inc, which governs the management of session data. Zoom AI records and analyzes each session to generate clinical summaries and insights for documentation and treatment planning. All recordings are permanently deleted once the summaries and insights are completed at the end of each session.

Zoom AI employs encryption, continuous system monitoring, and other security protocols to protect client data in compliance with HIPAA regulations.