SOOL Psychology - Consent & Therapy Agreement

Dr Jo Holmberg, Chartered Psychologist (BPS). Online psychological therapy.

Section A - Client aged 16-17

This agreement is between Dr Jo Holmberg (SOOL Psychology) and ________________________ (“you”), with the involvement of your parent(s) or guardian(s). Sessions are held online via Zoom.

1. Your consent to therapy

At 16 or 17, you are able to consent to your own therapy. By signing below, you agree to take part.

2. Parental involvement

Therapy with young people works best when parents are informed and supportive, with your agreement. Your parent(s) or guardian(s) sign below to confirm they support your therapy and agree to the arrangements, including fees.

3. Confidentiality and its limits

What you tell me is confidential. I will not share it with anyone, with the following exceptions:

where I am seriously concerned about a risk of harm to you or to another person;
where I need to act to keep you safe (safeguarding); or
where I am required to share information by law (for example, a court order).

Wherever it is safe to do so, I will talk to you first before sharing anything.

4. What I share with your parents

In our first session, you and I will agree together what you are happy for me to share with your parents. I usually check in with parents after the first session and then about once a month, within what you and I have agreed. Parents and clients are both welcome to email me with questions between sessions (my open-door policy).

5. Fees and cancellation

As already discussed: £150 per session. Please give at least 24 hours' notice to cancel or rearrange; otherwise, the session may be charged.

6. Online sessions

Please join from somewhere private where you will not be interrupted. So that I can help if there is a technical or safety problem, I hold an emergency contact and the address where you usually are during sessions:

Emergency contact (name and number): _____________________________________________

Usual location during sessions (address): _____________________________________________

If we lose connection during a session, I will try reconnecting Zoom or call you on your mobile.

7. Data protection

I hold and use your information in line with my Privacy Notice, which explains your rights under the UK GDPR and the Data Protection Act 2018. By signing, you consent to my holding and processing your health information for the purpose of your therapy.

8. Signatures

Client’s name: ____________________________________________________Date: ______________

Parent/guardian (with parental responsibility): ________________________ Date: ______________

Second parent/guardian (if applicable): ______________________________Date: ______________

Practitioner (Dr Jo Holmberg): ______________________________________Date: ______________

Section B — Client aged 18 or over – Young Adult

This agreement is between Dr Jo Holmberg (SOOL Psychology) and _____________________ (“you”). Sessions are held online via Zoom.

1. Consent to therapy

By signing below, you consent to take part in psychological therapy with me.

2. Confidentiality and its limits

What you tell me is confidential. I will not share it, with the following exceptions:

where I am seriously concerned about a risk of harm to you or to another person;
where I need to act to safeguard a child or a vulnerable adult; or
where I am required to share information by law.

Wherever it is safe to do so, I will discuss any disclosure with you first.

3. Sharing with others (optional)

As an adult, you decide whom I may speak to. If you would like me to be able to speak with a named person (for example, a parent), please complete the following. You can change or withdraw this at any time.

I authorise Dr Holmberg to speak with:____________________________________________

- relationship: _____________________________ about matters I agree on – these may vary across sessions.

4. Fees and cancellation