Dr. Anton Schweighofer
Registered Psychologist #1409
501-3292 Production Way
Burnaby, B.C., V5A 4R4
&
North Shore Stress and Anxiety Clinic
330 – 145 Chadwick Court
North Vancouver, B.C., V7M 3K1
(604) 786-3073
Statement of Understanding & Consent to Treatment
Welcome to my practice and to my treatment methods and policies. It is your right, and
responsibility, to choose the psychologist and treatment that best suits your needs. To help you
make your choice, and to facilitate our work together, here is some basic information about my
practice, and about therapy. Please read this information carefully and ask me to explain
anything that you do not understand. This statement, in its entirety, serves as our agreement to
our respective rights and responsibilities as psychologist and client. You will be asked to sign it
after reading it, and before we begin our therapy together.
Benefits of Therapy
Therapy can help a person to gain new understandings about his or her problems and to learn
new and more effective ways of thinking and behaving with regard to these problems. Problems
such as panic and anxiety, posttraumatic stress, phobias, depression, grief, relationship struggles,
chronic pain, and concerns about mid-life and aging, can be helped with a broader understanding
of the issues, and a commitment to change. Therapy can help a person develop new skills,
determine emotional blocks preventing change, and change old and ineffective behavior patterns.
Therapy can also contribute to improved ability to cope with stress and difficult situations, and
can increase ones’ understanding of oneself and others.
Dr. Schweighofer provides psychotherapy services drawing largely on cognitive behavioural
approaches.
Risks of Therapy
I acknowledge that Dr. Schweighofer has advised me that, while there are potential benefits to
therapy, there is no guarantee of success, and there are potential risks. I have been advised that
during therapy, strong, sometimes negative, emotions and memories may be evoked, and that
changes in awareness may alter my self-perceptions and ways of relating to others. I have been
advised that the process of personal change is varied, and individual. I understand that it is
important that I mention promptly to Dr. Schweighofer any concerns or questions that I may
have at any time during the process of therapy. I understand that I may discontinue treatment at
any time, and am not required to explain my reasons.
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Confidentiality and Limits of Confidentiality
As a psychologist, I keep a record of health care services that I provide to each client. According
to practice guidelines, records are kept for seven years and then destroyed. This includes emails.
It is important to remember that email is generally not a secure form of communication and, as
such, it is best that you do not share highly personal information with me via email. Email and
text messaging are best used for tasks such as changing appointments or other administrative
issues. Exceptions to this should only be undertaken with an understanding of the non-secure
nature of email and texting.
The information from your intake assessments, and therapy, is confidential, and will not be
disclosed without your written consent, unless the law requires otherwise.
Anything discussed in therapy, and all information obtained about you from any source,
including the fact that you are my client, is confidential. There are, however, exceptions to the
privilege of confidentiality as required by law that apply:
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If a child is in need of protection and this becomes obvious during an interview, then
according to the law, I must notify the appropriate authorities.
If you are actively suicidal, I may contact your doctor, family, or the police.
If you are intending to harm another person, by law, I must notify the appropriate
authorities.
If you drive a motor vehicle, and provide me with information suggesting that your
ability to drive is impaired for whatever reason, I may need to contact your family
doctor, or the Superintendent of Motor Vehicles.
If an insurance company such as ICBC, or WorkSafe BC, is involved, they may require
that I provide working diagnostic information, or complete a report, which I will review
with you.
If your file is subpoenaed by the Court, I will ask you to sign a waiver from all liabilities
for such releases, prior to forwarding assessments and clinical notes.
If I am requested to appear in Court, I may end up testifying about the results of our
sessions.
Please discuss any releases you are asked to sign. I know all this may sound ominous, however
it is best for you to understand “up front” what is involved—especially the risks.
Consent
Your signature on this form will be considered as legal consent for psychological treatment and
its risks. For example, there are some aspects of psychological treatment that you may find
upsetting and even painful:
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Being asked about very private and personal experiences in your life;
Being asked about and re-living original events that have brought you to treatment;
Hearing from me about the psychological dynamics with which you are dealing either
during the session or from material that I prepare about you;
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And, in cases where our information is available to others (family, medical doctors,
insurance companies, lawyers), knowing that very personal aspects of your life are
disclosed.
Appointment Cancellation
Twenty-four (24) hours notice before your scheduled appointment is required in order to
avoid being billed for a missed appointment. Earlier notification is greatly appreciated.
Please call as soon as you can. We may be flexible for emergencies.
Fees
The current fee is $185.00 per hour for psychotherapy clients. All sessions are billed for one
hour, with an understanding that 50 minutes are for direct client contact, and 10 minutes are
for file review, note taking, and other administrative tasks related to the file.
Other fees apply in the case of court involvement where a lawyer is billing me for their
services. This fee schedule will be provided to you upon your request, and in the event you
are anticipating court involvement.
Clients pay by cash or cheque.
You will be charged $15.00 for NSF cheques. Accounts not paid will be charged interest of
24% per annum from the date of billing.
Office Arrangement
For business purposes, I share my office with other clinicians whose certificates may appear
on the office wall. You should note that I have no formal partnership or formal professional
affiliation with these individuals. The office is shared as a matter of convenience.
College of Psychologists
The College of Psychologists of British Columbia licenses and regulates the practice of
psychology in BC. If you have concerns regarding the service you have received from a
psychologist, a good first step is to talk directly to the registrant. If you are still not satisfied
and you feel that you have been mistreated by a registrant, or that the registrant has violated
the Code of Conduct in some way, consider the following course of action: discontinue
receiving services; discuss your concerns with someone you trust; and/or submit a written
complaint to the College. All complaints must be made in writing. To help you, the College
has developed a form that assists you in explaining the nature of the allegations. You may
download the form directly from the College’s website at www.collegeofpsychologists.bc.ca
under For the Public/Making a Complaint.
Upon reading and understanding these policies, please sign below.
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I have read and understand the Disclosure Statement in its entirety. Fee arrangements and
terms of confidentiality have been clearly made. My signature below indicates that I agree
to the terms herein and that I wish to enter treatment on those conditions.
Client Signature: _________________________________________________
CLIENT INFORMATION
DATE: _________________________
NAME: _________________________
ADDRESS (INCLUDE POSTAL CODE):
___________________________________________________________
___________________________________________________________
PHONE: (HOME) ____________________ (WORK) _________________
(CELL) ___________________
OK TO LEAVE A MESSAGE? H:____ W:____ C:____
EMAIL _______________________________________________
REFERRAL SOURCE: __________________________________________
BIRTHDATE: ________________________
BIRTH PLACE: _______________________
EDUCATION/TRAINING: _________________________
OCCUPATION: _________________________________
RELATIONSHIP STATUS: ______________________________________
PARTNER'S NAME (if applicable): ________________________________
EMERGENCY CONTACT (NAME AND PHONE #)
_____________________________________________________________
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CHILDRENS' NAMES AND AGES (if applicable):
____________________________________________________________
PHYSICIAN NAME AND PHONE #:
__________________________________________________
HEALTH PROBLEMS: __________________________________________
MEDICATIONS: _______________________________________________
CONCERNS: In you own words, what is the nature of the concern that you wish to address in
therapy? Feel free to give as little or as much detail as you wish.
GOALS: What would be different in your life/in you if therapy had been successful? At this point
it is best to be as concrete as possible. For example: “I want to be able to go out on a social
outing twice a week and keep my anxiety level at no higher than a 4 on a 0 to 10 scale. “ You
may find it difficult to express your hopes for therapy in the form of a goal but it is important to at
least start to think about this. We can discuss this further when we begin therapy.
GOAL #1 ____________________________________________________________
____________________________________________________________________
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GOAL #2 ____________________________________________________________
____________________________________________________________________
GOAL #3 ____________________________________________________________
____________________________________________________________________
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