Informed Consent Form

I have read and understand all of the information on the 4peaceofmind web-site regarding the nature of this online counselling and psychotherapy practice.

I understand that even though the most up-to-date technology will be used to ensure the privacy of any information received by 4peacofmind, information on the internet cannot be absolutely secured.

I understand that 4peaceofmind will never receive any of my financial information from PayPal or Amazon.

I take responsibility for protecting the privacy of any information I receive, generate, and store on my own computer.

I understand that Susan Rotella is legally obligated to break confidentiality under the following circumstances:

  • if I indicate an intent to harm myself or another
  • if I share knowledge of the abuse of a minor – essentially this means anything that may cause a minor psychological harm/distress, and may lead to long-term psychological problems, for example, information regarding direct verbal/psychological and/or physical/sexual abuse of a minor, as well as indirect abuse that occurs as a result of witnessing abuse, living in fear of abuse, experiencing neglect, etcetera
  • if she is subpoenaed by a court of law

I agree to review and familiarize myself with the emergency resources that are available to me in my area of residence.  If at any point in time I enter a state of crisis and feel likely to hurt myself or another person, I take full responsibility for obtaining immediate and appropriate assistance as well as for any actions I might or might not take.  I understand that emergency situations require face-to-face intervention and accept that crisis intervention cannot be conducted online.  In the event of an emergency, I agree to contact at least one of the following resources:

  • 911
  • hospital emergency room
  • a doctor
  • crisis line or crisis agency
  • trusted adult friend or family member

I understand that online counselling and therapy is not suitable for cases involving domestic violence and/or any form of abuse toward minors.  If I am currently involved in situations involving domestic violence or any form of abuse toward children, I will not seek help from Susan Rotella.  I will instead seek help from another counsellor and/or the police.  I understand that if an abusive situation arises, and Susan Rotella is unable to adequately determine the safety of me or my children, she is legally obligated to contact the relevant authorities to complete an assessment of the safety of my household.

I understand that Susan Rotella is licensed to practice in Canada through the Canadian Professional Counsellors Association.  If I reside outside of Canada, I take responsibility for informing myself of and complying with any laws in my area of residence that may pertain to online counselling.

By typing and submitting my name, e-mail address, and entering “Yes” below, I acknowledge that I fully understand and accept all of the conditions noted above.