Expressive Arts Therapy Informed Consent Agreement
YOUR NAME ADDRESS AND CONTACT HERE
EXAT NAME
• diplomas, degrees, other credentials, professional associations listed here
About Expressive Arts Therapy (EXAT)
General Description of EXAT here
Style of Practice
Description of your EXAT practice here
Example: I use an intuitive client-centered approach following the clients’ emotional, cognitive
and somatic cues. I offer a flexible structure using the following principles as a loose guide: the
EXAT joins the client in a process of sensitization, exploration, repetition, validation and
evaluation. I believe that the client is their own best expert, and given a safe and supportive
environment, will intuitively find their way to their own inner resources.
Role of Therapist (amend as required)
• to maintain a comfortable studio space
• provide art materials, musical instruments, costumes, toys, etc.
• support healing processes
• act as a witness to clients’ healing journey and life story
• to offer arts-based choices to the client, to interact with the client and the art that results
• when appropriate, create the art together
• offer client different ways of using the materials
• to provide a supportive healing environment that welcomes surprises
and a deepening of the clients’ creative experience
• refer the client to additional outside support if it is appropriate
• to provide confidentiality to the client
Confidentiality
I will not share personal information about you, your life story or what happens
in any of our therapy sessions to any one outside the following three exceptions:
1) If the client requests that the therapist release their personal information to an outside party.
In this event a Form 14 from the Mental Health Act would be filled out and then signed by
the client and the therapist before releasing the filled out Form 14 to the third party.
2) By Federal Law a therapist is required to:
*Report to authorities when they suspect a child is being abused
*To comply with a court ordered subpoena
3) Common Law dictates that it is the responsibility of the therapist to report to authorities, or the
necessary peoples when they are privy to plans that a client has to physically harm themselves or
another.
Therapy Rates:
Your EXAT rates here
Cancellation:
I require 24 hours notice for the cancellation of an appointment. I can be reached by phone or email. In the case of cancellation without notice or cancellation with less then 24 hr notice, the
client will pay the full amount of the missed session at the next session, unless we both agree
cancellation was due to circumstances beyond your control.
Session Protocol:
Payment is preferred at the _________ of the session. I usually leave ________between clients to
avoid any overlap and to reflect on the session, make notes or process through the arts myself.
Recommended Schedule:
A commitment to weekly or bi-weekly sessions is encouraged to maintain the continuity and
focus of the work.
Duration of Therapy:
This varies according to the client’s need. It may be from a few months to a few years.
End of Therapy:
The client is free to terminate at any time. There is a closing process.
Risks Associated with Expressive Arts Therapy:
As with any psychotherapeutic process, long buried feelings may emerge.
This can sometimes make the client feel worse before they feel better.
Code of Ethics:
In my EXAT practice, I follow the Code of Ethics set out by the Ontario Expressive Arts Therapy
Association (OEATA) of which I am a member. See attached Code of Ethics.
Supervision:
The OEATA Code of Ethics states that therapists must be clinically supervised. I am supervised
by Expressive Arts Therapist__________________. The supervisor is bound by the same rules of
confidentiality as the therapist. In supervision, I will discuss general themes of a session, not
personal details that would identify the client.
Your Questions
I welcome any questions about my private practice.
I understand and I am in agreement with the above stated conditions.
I, _____________________________hereby agree to participate in Expressive Arts
Therapy facilitated by _______________________ and acknowledge that I have been informed
regarding the nature of such therapy.
Signature: __________________________
Date: __________________________
Privacy Policy
Appointed Privacy Officer:
Your name
Personal Information
Personal information is defined as information about you that would allow
an outside party to distinguish, identify or contact you.
Confidentiality:
I will not reveal personal information about you, your life story or what
occurs in therapy sessions to an outside party (outside of the exceptions below):
There are three circumstances when personal information may be revealed to an outside party:
1) If the client requests that the therapist releases their personal information to an outside party. A
‘Form 14’ from the Mental Health Act would be filled out and then signed by the client and
therapist before requested form is released between the therapist and the third party.
2) By Federal Law a therapist is required to:
• report to authorities when they suspect a child is being abused.
• to comply with a court ordered subpoena
3) Common Law dictates:
• that it is the therapist’s responsibility to report to authorities or the necessary peoples when
they are privy to plans that a client has to physically harm themselves or another.
*Please note
The OEATA Code of Ethics state that therapists should be clinically supervised. I am clinically
supervised by an experienced Expressive Arts Therapist. Supervision occurs privately in the
supervisor’s office. The supervisor is bound by the same rules of confidentiality as the therapist.
During the supervision meetings, I will not discuss any personally identifying details about my
clients and will instead discuss general themes.
What type of files do I keep?
I store personal contact information, progress notes, referral notes, billing documentation and art
work that the client has not taken home for the purpose of: keeping track of appointment dates,
important details of the client’s life story, what occurs in sessions and financial aspects of the
private practice. Products of the therapy session, art, will be kept up to one year at which time
they will be recycled.
Storage of Informational files:
All files are updated after each session and stored in a folder in a locked filing cabinet in the
EXAT office and no other information will be kept on file. All files will be kept for seven years
after termination of therapy, at which time they will be shredded. When necessary, all files will
be moved in a secure manner.
Your Rights:
*At any time a client may request to look at his or her own files (personal contact information,
progress notes, referral notes, billing documentation and art work). Upon receipt of a written
request, files will be made available to the client within a two-week time period.
* In keeping with your privacy needs, please let me know if, or how, you would like to be greeted
if we encounter each other in a public setting.
* I welcome any question or discussion related to your privacy rights.
* All conditions relating to confidentiality mentioned above are in keeping with the Privacy Act
of Canada. To read further details about the Privacy Act, please refer to the brochure and/or
Privacy Act that is provided for you at the entrance to the Expressive Arts Therapy Studio.
For further information on the Privacy Act contact:
Privacy Commission
112 Kent Street
Ottawa
KIA 1H3
1-800-282-1376
info@pricom.gc.ca
I understand and I am in agreement with the above stated conditions.
Expressive Arts Therapy Client name (print): _________________________
Signature: __________________________________
Date:
Expressive Arts Therapist name (print): _________________________
Signature: _________________________________
Date:
Ontario Expressive Arts Therapy Association (OEATA) Code of Ethics
Care and Respect for the Rights and Dignity of Persons
In view of the growing complexity and intersectionality of modern lives, the Expressive
Arts Therapist (EXAT) is against all forms of discrimination, bias or prejudice and
believes in the practice of equity. This includes discrimination based on race, class, size,
gender, sex, sexual orientation, age, ability, religion and legal status. The EXAT
proactively considers the needs of those we serve by supporting clients and their best
interests, by honouring our commitments to them, and by refraining from any
actions which risk harm. We recognize our individual and collective responsibilities to
society, to the Expressive Arts Therapy field and, especially, to those we serve.
Continuing Education
The EXAT is committed to providing service of the highest quality. To this end the EXAT
continues to engage in satisfying the professional requirements of competency
through ongoing therapy, supervision, contribution to the field, studio and clinical
practice. We continually inform ourselves and expand our skills in therapy, the arts, and
community service. We practice in accordance with the best practices of our profession,
and continually expand our professional competence through professional development.
Autonomy
The EXAT provides the client or legal decision-maker, accurate and thorough
information upon which they can make informed decisions according to their own needs,
beliefs and values with regard to our services, processes, and interventions. Inherent
benefits and risks are communicated clearly, as well as options and alternatives. We
respect client choices and decisions.
Confidentiality
The EXAT believes that clients have the right to confidentiality. The Expressive Arts
Therapist safeguards and maintains confidential personal, family and community
information obtained in the context of the professional-client contract and relationship in
compliance with the Ontario Privacy Act.
Integrity in Relationships
We believe that therapeutic relationships and their benefits rely on trust and empathy.
Trust is dependent on the demonstrated integrity of the Expressive Arts Therapist. The
EXAT is self-aware and truthful. The EXAT maintains an implicit and explicit commitment
to the client and client groups, to themself, to each other, to our profession, to other
professionals and to the larger world. We exercise healthy boundaries and evaluate all
contact and relationships with clients for their risk or benefit to client health and wellbeing according to the highest standards of ethical behaviour as outlined in the code of
ethics and standards of practice.
Aesthetic Responsibility
Aesthetic responsibility is the ability to use self-awareness of bodily sensory experience
and imagination as vehicles for creativity, inter-modal artistic expression and
phenomenological exploration of the insights offered by images and the shaping thereof.
The EXAT believes that attunement to sensory experience and the imagination are ways
to access creative capacity and a way to understand relationships with the worlds
we inhabit. The EXAT does not reduce artistic expressions to expressions of self that
can be analyzed for psychological content. Rather, the EXAT views artistic expressions
as expressing worlds and relationships. We explore these worlds and relationships
through a specialization termed “aesthetic responsibility”.
Accountability
The Expressive Arts Therapist recognizes that as a member of a self-regulated
profession, we have a responsibility to hold our selves, and each other, accountable for
our actions, accountable to the people we serve and to the larger community. The EXAT
exercises her, or his, best professional judgment as guided by the values and
responsibilities outlined in the OEATA Code of Ethics and Standards of Practice, as
well as being bound by law and the regulations of the Ontario College of
Psychotherapists. The Expressive Arts Therapist makes every reasonable effort to
resolve ethical dilemmas through self-reflection and consultation. Where there is breach
of ethics, the EXAT makes every effort to repair loss of trust and accept responsibility for
errors in judgment.
Social Justice
The EXAT believes that as health care professionals, (and educators, researchers etc.),
we have an extended responsibility to advocate for the individual and collective rights
and social determinants of health of our clients and communities. The EXAT believes in
the basic human capacity to shape and create our worlds according to our individual and
collective needs, which necessitates that we empower clients to identify and access
their resources with regard to self-advocacy.