CONSENT FORM

In Compassionate Integration, Deborah Davies brings together her skills to help people reconnect to their essence, communities and environment. She’s a yoga teacher, massage therapist and facilitator of detox retreats. She has completed the year long training of Gabor Maté’s Compassionate Inquiry Professional Training Program, and is undergoing trainings of IFS and Family Constellations therapy. She is not a licensed psychologist or mental health professional.

SERVICE PROVIDED

1:1 sessions to uncover the unconscious dynamics that run our lives and find more authentic and compassionate ways of relating with ourselves and others.

CONFIDENTIALITY

The client understands that there are exceptions to legal confidentiality and professional ethics. These exceptions exist as they are legal obligations professionals must adhere to.

Exceptions include but are not limited to:

1) Files required to be submitted by a court of law;

2) Disclosed or suspected child abuse or neglect;

3) Perceived threats of violence/risk to oneself or to others (i.e. threats of suicide, threats to injure or harm others);

4) Report to the appropriate authorities in the event a Regulated Health Professional (i.e. social worker, psychologist, physician and surgeons, dentists etc.) of whom Deborah Davies was told the name, behaved in a sexually inappropriate manner with the client.

The client understands confidentiality is to be maintained at all times. Confidential means that no information, using people’s names/identification, is shared outside the sessions.

Unless disclosure is requested or permitted by the client or unless it is required by law, Deborah Davies shall keep all personal and identification and session information STRICTLY CONFIDENTIAL. That is, Deborah Davies will not disclose your name, identifiable information or details of the substance of your session unless a legal exception exists. For example, if Deborah Davies has reason to believe that you may be at imminent risk of harm to yourself and/or others, she is under legal and ethical obligation and only then Deborah Davies may disclose and discuss relevant details with third parties but only on a need to know basis.

The client understands that sessions are held over Zoom which isn’t a secure or encrypted platform. Similar to using cell phones, email, and social media, privacy may be compromised which can lead to breaches of confidentiality, despite our best efforts to ensure confidentiality.

ACKNOWLEDGEMENTS

The client acknowledges that:

  • he/she/they are 18 years of age or older.
  • he/she/they are voluntarily engaging with Deborah Davies.
  • Deborah Davies will rely on information provided by the client and the client affirms that all information provided to Deborah Davies is true and accurate to the best of the client’s knowledge and belief.
  • the sessions with Deborah Davies should never be used in place of professional counselling or medical care.
  • the sessions with Deborah Davies do not constitute legal, medical, business or financial advice.

THE CLIENT TAKES FULL RESPONSIBILITY FOR ANY ACTIONS, INTERPRETATIONS, DECISIONS TAKEN OR MADE BASED ON SESSIONS WITH

DEBORAH DAVIES. THE CLIENT AGREES TO HOLD DEBORAH DAVIES COMPLETELY HARMLESS AND FOREVER RELEASES AND FULLY DISCHARGES DEBORAH DAVIES OF AND FROM ANY AND ALL CLAIMS, DEMANDS, CAUSES OF ACTION AND RIGHTS, WHETHER KNOWN OR UNKNOWN, RELATING IN ANY WAY TO THE CLIENT’S DEALINGS WITH DEBORAH DAVIES.

By booking sessions with Deborah Davies, the client states that he/she/they:

  • have carefully read and reviewed this consent form;
  • have understood it and accept the risks and limitations involved in voluntarily seeking the services provided by Deborah Davies.
  • have asked any of the questions present at this time.
  • have understood all of the above conditions and hereby consent to participate in session(s) with Deborah Davies.
  • have verified that entering their name below is in lieu of them signing this document when done electronically.

Client understands, accepts, comprehends and provides consent for the information provided in this document. Client has read and agreed to the terms above (date and client signature required)