Once new clients have determined that they wish to be seen for consultation, a consent form must be submitted. It is preferable to print and sign by hand, but if this is not possible, please copy and paste the content below into an email, initial and 'sign' where indicated, using the keyboard.

 

 

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I,_________________________, agree to participate in a consulting process with Annette Poizner, MSW, Ed.D., RSW, understanding that the services provided are for my own lifestyle guidance, education, and contemplation about life, function and personality.I understand that in performing psychotherapy, Annette Poizner looks at the component parts of personality to consider strengths, weaknesses, talents and obstacles. I agree that I am the type of person who enjoys self-insight and am otherwise comfortable receiving constructive feedback, with regards to the identification of weaknesses. I understand that insight-oriented work is not recommended for anyone uncomfortable receiving feedback, negative and positive, about self, personality and personal function, and about conjectured areas for improvement. I understand that this process is exploratory and designed to stimulate discussion and reflection. I understand that I am the arbiter of whether Annette Poizner's insights are relevant and accurate.

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I understand that Annette Poizner's counselling practice involves the use of techniques which may include Ericksonian therapy, lifestyle counselling, dream interpretation, Eye Movement Desensitization & Reprocessing, Neuro Linguistic Programming techniques, hypnosis, guided imagery, skill development training, rehearsal, affirmations, psychoeducation, among other techniques. I understand that her work is designed to facilitate personality restructuring assisting the client in the task of achieving inner balance and integration of all the dimensions of Self, this in an effort to reduce symptoms, improve wellness, and improve personal and vocational effectiveness. I understand that Annette Poizner is not able to guarantee specific results and I can give her feedback about our work at any point, and re-evaluate the benefit of her services. 

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I understand that reviewing painful material from the past can potentially reawaken symptoms or negative feelings. I understand that some people undergoing personality change may experience feelings of confusion, disorientation, even some depression, while undergoing the therapeutic process/negotiating personality restructuring and that dreams may usefully hint towards what is occuring internally, in response and reaction to the work, and in response or reaction to everyday happenings. I understand that Annette offers feedback about dreams and memories that I retrieve in sessions, often advancing tentative ideas about what they indicate, and I am to determine whether her interpretations seem accurate and meaningful, and can correct, revise or discuss her formulations.

 

I understand that our process may involve retrieving memories in session and that if there is a history of trauma, with memories which will be untoward to revisit, I will advise her and we will tread with care. I also understand that if there is a history of trauma, talking about personal issues can awaken difficult feelings in the aftermath of the session, am aware that the process might wake up old pain from the past and am willing to endure this, if our therapeutic work requires some discussion of painful issues.  I understand that if I experience negative feelings or reaction to the work I do with Annette Poizner, I should alert her to this fact so that we can consider what might be happening and whether we can ameliorate the situation, promoting more comfort.

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I confirm that I am soliciting consultation on my own behalf and not as an agent for any federal, provincial, municipal or professional agency on a mission of entrapment or investigation. I agree that I will not misrepresent my identity.

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I understand that Annette Poizner's consultation services are designed to promote self-insight and reflection about my personality. I understand that Annette Poizner has an interest in 5 Element Theory from Chinese philosophy as a frame of reference for looking at personality, that this lens provides an interesting lens to think about the personality. I understand that 5 Element Theory is a minor aspect of Chinese Medical Theory and that Annette is in no ways offering (or capable of) diagnosis within the Chinese Medicine system. I understand that Annette is not a trained or licensed Chinese medical doctor. I understand that if she speculates about imbalances in the elements, proposing elemental factors might be at play in my constitution, she is conjecturing about general trends that may or may not be at play in my personality. I understand that for detailed feedback from a qualified Chinese medical practitioner I would pursue treatment with such a professional, and that Annette Poizner supports the idea of consultation from this perspective.

 

 I also understand that Annette Poizner has an interest in spiritual models and may share insights from traditions which she finds interesting or potentially relevant. I understand that in bringing up these ideas, they fall in the realm of speculative ancient wisdom and have not been demonstrated as necessarily valid via scientific investigation. Annette Poizner introduces said ideas for the sake of interest and to advance potential insight and I may find application or otherwise reject this frame, if it does not seem a fruitful angle of contemplation. I understand I am encouraged to share my reactions to any speculative models she advances and understand that Annette can tailor our discussion around my interests or accomodate my disinterest, as is the case.

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I fully understand that Annette Poizner cannot diagnose, treat, cure or prevent any nutritional, medical or psychological disease, disorder or condition. I further understand that she cannot advise, recommend, suggest or counsel me on any medical or dietary treatment, condition, disorder or disease.  She does not diagnose, treat, or otherwise prescribe for any disease, condition, or illness, or perform any act that would constitute the practice of medicine for which a license is required. Her services are intended as consultation for building wellness, promoting resilience and sharing nutritional knowledge as it relates to its effects on the human body and its interrelated systems. I agree that if she has any suggestions that will relate to diet, supplementation or any other therapeutic activity, I will check with my own medical doctor before commencing. I take full responsibility and release her from liability with respect to any advice or treatment/care which I may follow. 

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I understand that online counselling services include consultation and treatment using interactive audio, video, and/or data communications. I understand that online counselling services involve the communication of my medical/mental health information to the above referenced provider. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment; nor risking the loss or withdrawal of any benefits to which I would otherwise be entitled. I understand that the laws that protect the confidentiality of my medical information also apply to online counselling services.

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I understand that meeting(s) with Annette Poizner will be conducted over a PHIPA compliant technology platform. I understand that I must use PHIPA compliant technology to avoid the risk of hacking and take responsibility for ensuring that my technology is adequate to minimize the risk that our confidential discussion will be accessed by others. I also take responsibility to protect my confidentiality by conducting our session in a private environment where others will not hear our discussion. 

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I understand that the platform/software Annette Poizner uses is considered secure and encrypted and meets both the Personal Information Protection and Electronic Documents Act (PIPEDA) and the Personal Health Information Protection Act (PHIPA) standards of use.  I understand that there are certain risks involved in using electronic means to conduct a personal conversation and that those risks have been explained to me. I recognize that therapy by telephone is not reliably confidential and I am willing to take this risk. I release Annette Poizner from liability if her PHIPA compliant system is attacked electronically creating a privacy breach. I also understand that occasionally the technology can glitch which can interrupt our session temporarily. I understand that when that occurs we will pause our meeting and resume as soon as the problem passes.

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I understand that regular email that is not encrypted is not PHIPA compliant and can be hacked, and may not be adequately secure. If I am sending confidential attachments or messages, I best do so using virtualcare, her PHIPA compliant platform which provides us with a way of sending messages and attachments that are encrypted. 

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I acknowledge that Annette Poizner is located in the province of Ontario. I agree to bring any dispute to  Annette Poizner's attention as soon as possible and without undue delay. Annette Poizner agrees to make every effort to resolve any dispute between us in a timely manner. I agree that the Courts of Ontario shall have exclusive jurisdiction to hear any complaint, demand, proceeding or cause of action, whatsoever arising from or in connection with the consultation services that I receive or from any other aspect of the relationship between myself and Annette Poizner. 

Confidentiality: I understand that any information Annette Poizner collects about me will be held in the strictest confidence, except when released by me or specifically required by law. I understand that, by law, Annette Poizner is obligated to break confidentiality only if doing so protects me or identified others from serious and foreseeable harm.  I have the right to waive this confidentiality agreement in whole or part at any time. 

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I confirm that the nature, risks, benefits, consequences of the treatment plan or procedures and related matters have been explained to me. I am satisfied with and understand the the information I have been given and consent to the assessment or treatment plan that has been discussed. I understand that I may, at any time, withdraw from any treatment or procedures.

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I acknowledge that by signing this disclaimer once, it will cover all subsequent visits. I confirm that this agreement is being signed voluntarily and not under duress of any kind.

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I agree to pay Annette Poizner $100 for each hour of her work. 

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I also understand that in the event we have three successive scheduled meetings that are cancelled or don't occur, or three cancellations which occur within a six week period of time, Annette will refer to another practitioner whose calendar may be more accommodating to my availability.

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By signing below, I acknowledge that I have read and understand this document, and have received acceptable answers to all of my questions about her services and consent to receive consultation from Annette Poizner.

 

Date________________

Client name___________________

Client signature_____________________________

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Address:____________________________________

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Date of Birth ________________________________

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Please note: Full name, current address and date of birth are required in order to initiate treatment, allowing me to function in compliance with the codes that guide my professional practice.

 

Telephone number:__________________________