Loved One Session Consent Form
By booking a Loved One Session with a Licensed Therapist (“Care Team”), I indicate my consent which authorises Alavida Health Ltd. (“Alavida”) to collect the information needed for the Care Team to deliver the educational session and provide best answers to my questions as possible.
I understand that the Loved One Session cost is $200.00 plus applicable taxes.
The Loved One Session will consist of a 40 minute appointment with the Care Team wherein my personal information, treatment programs and/or other care alternatives will be discussed. I will have the opportunity to ask questions that relate to helping motivate a loved one to make change and basic information on getting started and understanding how problem drinking develops, how change takes place and different options for support and treatment with the Care Team. Due to the time-limited nature of the Loved One Session, I understand that I will not have the ability to discuss an assessment about the drinkers mental health or medical history and that this session will not be a comprehensive review of family medical or mental health history.
CANCELLATION OF APPOINTMENT
In the case that an appointment cannot be kept, Alavida requires 24 hours’ (excluding weekends and holidays) notice to cancel or reschedule appointments. In the event that I am unable to provide sufficient notice I understand that my appointment will be considered “missed” and I will be charged in full.
LIMITS OF CONFIDENTIALITY
Information discussed with Alavida’s Care Team is confidential, and is not shared without the client’s written permission except under the following circumstances:
- If the client is judged to be at serious risk of doing significant harm to himself or herself, or to someone else.
- If the client reports information indicating that a vulnerable person is in need of protection (e.g. a child or elderly person being abused).
- If the client holds a driver’s license and is not safe to be operating a motor vehicle.
- If records are subpoenaed by a court of law.