FAMILY SUPPORT SERVICES
INFORMED CONSENT FORM
Please read and discuss any questions you may have about the Informed Consent Form before signing it.
In case of discrepancies between the English and Chinese versions, the English version shall apply and prevail.
The counselling process at Focus on the Family Malaysia (FOFM) is a partnership between you and a trained counsellor to address areas of concern, dissatisfaction or dilemmas in your life, with the aim of helping and guiding you professionally. Generally, it takes about 4 to 6 sessions for a counsellor to address your specific area of concern. However, should you present a new presenting issue during your session with the counsellor, you will be advised by the counsellor to contact Focus on the Family Malaysia for a new appointment.
For counselling to be most effective, it is important that you take an active role in the process. This entails keeping scheduled appointments, being open with the counsellor, following through an agreed assignment(s) and discussing any questions you may have about the counselling process.
Counseling can have both benefits and risks. The counselling process can cause distressing emotions or produce unexpected behavioural changes, and it is important that you promptly discuss what you are experiencing with the counsellor.
By submitting this Informed Consent Form, you acknowledge that you understand the benefits and risks of counselling and you voluntarily consent to participate in the counselling process. Your submission also indicates that you understand you can withdraw your consent to participate and terminate the counselling process at any time.
FOFM recognizes that confidentiality is essential to effective counselling and we believe that for the sessions to work best, you must feel safe and secure about sharing sensitive, personal, and private information with the counsellor.
All interactions with FOFM, including scheduling of and attendance at appointments, content of your sessions, your progress in counselling, and your records are confidential, with the exception of email, video or phone counselling, where FOFM cannot guarantee that your information remained confidential as it could be at risk of being inappropriately breached due to the nature of the medium.
Exceptions to Confidentiality: Besides nature of counselling medium used, there are circumstances in which FOFM may share information about you without your consent. Possible exceptions to confidentiality include but are not limited to the following situations:
- FOFM counsellors work as a team and your counsellor may consult with fellow counsellors to provide the best possible care.
- If there are reasonable grounds to believe that you are threatening harm to yourself or another person, counsellors have a duty to warn the person in danger and to contact any persons in a position to prevent you from harming yourself or another person, including law enforcement authorities.
- If there is clear evidence of abuse being perpetrated against you, a minor or any other dependent persons, counsellors are under an ethical obligation to report this to the appropriate authorities.
- If you are under 18 years of age, your parents or legal guardian(s) have access to your counselling records and may authorize their release to other parties.
- When disclosure is ordered by a court and/or mandated by law.
By submitting this Informed Consent Form, you acknowledge that you understand and accept the nature and limits of confidentiality, and that you release and hold harmless the counsellor and FOFM from any departure to your right of confidentiality as a result of the Exceptions stated above.
Appointments can be made via the following options:
- Call FOFM at 603-3310 0792, Mondays through Fridays excluding Public Holidays between 10.00am and 4.00pm; or
- Email FOFM at firstname.lastname@example.org.
FOFM counsellors will first conduct an “intake” interview during the first counselling session. The purpose of this interview is to assess your concern(s) and determine the urgency and depth of assistance required. For cases where long-term intervention is required, several weekly sessions will be scheduled. We ask that you commit to attend all the sessions for the counselling to be effective.
It is also equally important that you arrive promptly for all your counselling sessions. If you arrive 15 minutes or more after the scheduled start time, your session may be rescheduled to another day/time to be agreed upon with the counsellor.
There is no fee for the counselling services. However, if you wish to contribute to FOFM, the suggested donation is RM 70.00 per session.
If you need to cancel or reschedule an appointment, please contact the counsellor or call FOFM twenty-four (24) hours in advance. This would allow FOFM to use the time for others. Please contact FOFM on Friday for appointments scheduled the following Monday. If you have three (3) no-shows or late cancellations, you may be discharged from the services of FOFM.
The counsellor reserves the right to cancel an appointment if you show up in a condition that may interfere with the quality of your counselling session, these include but are not limited to:
- You are unduly ill;
- You are on a course of medication that causes drowsiness
- You are with minors requiring your immediate attention;
- You are intoxicated; or
- You show signs of being under the influence of a prohibited substance.
You may terminate the counselling process at any time and if you choose to do so, please notify your counsellor. FOFM can provide you with the contacts of other counselling services/centers should you require them.
There are situations that are determined to fall beyond the areas of expertise or outside the scope of services provided by FOFM. In such situations, counsellors will not accept the request for counselling and will instead, provide referrals from its list of counselling network for you to obtain help.
FOFM wishes to remind you that email, video and phone are not secure forms of communication. Nonetheless, the counsellor will make every effort to maintain the confidentiality of all information concerning you.
FOFM maintains records of each session, whether conducted face-to-face, via email, video or phone. These records include a brief synopsis of the session along with any observations or plans for the next session.
Counselling records are stored as physical files in locked cabinets, only accessible to/by the counselling team. Counseling records are kept for 7 years after your last contact with us before they are securely destroyed in a way that protects your privacy.
Even though counselling records remain the property of FOFM, you may review the information concerning you by submitting a written request. You may also request that FOFM release information about your counselling to person(s) you designate with your expressed written consent.
To ensure a high standard of service, counsellors will periodically administer satisfaction questionnaires in the course of the counselling process. You may opt out of the survey if it causes discomfort.
Counsellors may also request for your counselling sessions to be recorded as audio or video recordings. Please be assured that your counselling sessions will NOT be recorded unless your expressed consent is received in a separate Consent to Record Form.
- By submitting the Informed Consent Form, I certify that I have read, understood and agree to abide by the information, terms and conditions contained herein. It also indicates that I have had the opportunity to discuss any questions and seek clarification about the information contained herein with the counsellor.
- By submitting the Informed Consent Form, I certify that the counsellor may contact and communicate with me using the contact details provided in the initial Intake Form. It also indicates that I will immediately notify the counsellor in the event of any changes to the contact details.
- By submitting the Informed Consent Form, I certify that I have voluntarily requested for counselling and I hereby give my consent to participate in the counselling process at Focus on the Family Malaysia. It also indicates that I understand I am free to terminate the counselling process at any time by notifying the counsellor.