Service Agreement

Telepsychology Service Agreement

This is a contract for Telepsychology services between A Holding Place and the Client identified in this service agreement.  This agreement shall be effective from the date that it is signed, until such time when both the Client and Clinician agree the service is no longer required, or the Client withdraws from the service and the file is closed.

A Holding Place

111 Pennywell Road
St. John's, NL A1C 2L2

T: (709) 738-0432 | F: (709) 738-3294

Telepsychology Service Form

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  • You must read through all terms and conditions before accepting.


    The Client understands that the Clinicians at A Holding Place are licensed professionals with one of the following: Newfoundland and Labrador Psychology Board, Newfoundland and Labrador Association of Social Workers and/or the Canadian Counselling & Psychotherapy Association, which regulates clinical practice in Newfoundland and Labrador and Canada

    Confidentiality Agreement

    A Holding Place and its Clinicians adhere to strict standards of confidentiality and will not disclose the Client's personal information to anyone without written consent from the Client to do so. This includes Telepsychology exchanges.

    The following are exceptional circumstances where laws and ethical standards of practice dictate that information cannot be kept confidential:

    1. If the Clinician has reason to believe that a person's life may be in danger, the Clinician will report the situation to the appropriate persons so that every possible measure can be taken to keep individuals safe. This applies to cases of potential suicide and/or specific threat to harm another individual.

    2. If it is believed that a child under the age of 18 years is at risk of being abused, has already been abused, or that someone who previously abused children poses a threat to children, the Clinician is required to notify the Police or appropriate child protection authorities.

    3. If the Clinician has reason to suspect that an adult lacks capacity to protect oneself and is in need of protection, the Clinician will report the situation to the appropriate adult protection authorities.

    4. A court of law can subpoena the Clinician and/or the clinical records for matters that are before the court or being investigated. A Holding Place and its Clinicians must comply with a subpoena for information.

    A Holding Place's ability to fulfill the obligations as described in 1, 2, 3 and 4 above is limited by the information that the client provides.


    I understand that while A Holding Place will use reasonable means to protect the security and confidentiality of information sent and received during Telepsychology communications, because of the risks outlined below, A Holding Place cannot guarantee the security and confidentiality of these communications:

    • I understand A Holding Place uses Zoom for videoconferencing, which is free for clients. Zoom uses 256 bit transport layer security, which improves privacy and security of the virtual session, however, I understand that publicly available videoconferencing may be more open to interception than other forms of videoconferencing.

    • I understand that the use of Telepsychology communications, such as telephone, videoconferencing and email, to discuss sensitive information can increase the risk of such information being disclosed to third parties. Despite reasonable efforts to protect the privacy and security of Telepsychology communication, it is not possible to completely secure the information.

    • I understand that by using a personal device to connect by telephone, and videoconference software, A Holding Place is not responsible for ensuring that my mobile device, personal computer, home internet or Wifi connection is secure. I understand electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings.

    • I understand that Telepsychology communications are subject to disruptions beyond the control of A Holding Place that may prevent A Holding Place from being able to provide services. Clinicians will try to troubleshoot the issue and/or connect with you via other means, such as telephone if videoconferencing is disrupted, or videoconferencing, if disruptions occur using the telephone.

    • I understand electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of A Holding Place.

    • I understand that even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist online or on a computer system.

    • I understand the videoconferencing link for the session will be sent to me by the Clinician via email, and that if I need to reschedule appointments, book appointments, etc., I must contact A Holding Place.

    • I understand that A Holding Place does not warrant the security of confidential material that becomes insecure because of actions the Client may take or that is a result of software that A Holding Place did not supply. Examples of security breaches that cannot be warranted include, but are not limited to:

    o Leaving confidential material on the computer screen for others to see
    o Storing confidential material on the computer you are using
    o The use of monitoring software

    Limitation of A Holding Place's Duty to Report Life Threatening Situations
    I agree to inform A Holding Place of any changes to my address, telephone number, email address, or other account information necessary to communicate, failure to do so releases A Holding Place from the ethical and/or legal obligation to warn of life threatening situations

    Limitations of the Nature and Scope of Services
    There are a few fundamental differences between Telepsychology and face-to-face counselling. In face-to-face counselling, the Clinician assumes responsibility for ensuring the setting and environment are appropriate for the work that is being conducted. With Telepsychology sessions, the Clinician can only control the setting and environment at the location where the Clinician is located. Therefore:

    • I agree I will be responsible to provide the necessary telecommunications equipment and/or the computer and internet access for my Telepsychology sessions.

    • I agree to arrange a location with sufficient lighting and privacy that is free from distractions or intrusions for my Telepsychology sessions. I will not connect to my session in a public or unsecured environment (e.g. an airport, internet café, or other open area, etc). I will not share emails or the video counselling connection details with others without permission of A Holding Place.

    • I agree not to record the live Telepsychology sessions and I understand that they will not be recorded or kept on my record with A Holding Place, unless previously discussed and approved.

    • I agree to be dressed as if I were attending an in-person face to face session.

    • I understand that I may benefit from Telepsychology but that results cannot be guaranteed or assured. I understand I may request to stop video or telephone sessions at any time and can request the other format or in person services, when available.

    • I understand that the Clinician may determine that due to certain circumstances, Telepsychology is no longer appropriate and that we should resume our sessions in person when available.

    • I understand that I have the right to withdraw or withhold consent from Telepsychology services at any time. I also have the right to terminate treatment at any time. I will provide notice of the withdrawal of consent by email or other written communication.

    Storage of Client Records and Personal Information
    I understand that A Holding Place will maintain a written record of the Client’s personal information and a progress note of the counselling sessions. This information will be securely stored on a shared drive or in a locked filing cabinet that only A Holding Place staff have access to. It will be kept for seven years after intervention has ended and will be destroyed after this time frame.

    I acknowledge the above risks and will not hold A Holding Place liable for any losses associated with participating in Telepsychology.

    Location of Services
    I agree that the counselling services provided by A Holding Place shall be considered, for all legal purposes, to be provided in Canada only and specifically in the Province of Newfoundland and Labrador.

    I understand and accept that A Holding Place does not provide emergency services. Because Telepsychology is taking place via the internet or telephone, A Holding Place cannot be held responsible for helping the Client manage a crisis. The Clinician cannot always be available and therefore the Client must manage the crisis by using resources other than those offered by A Holding Place. For minors we request that a parent be available by telephone during the session.

    If a crisis occurs, I understand that the protocol would be to call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I may also call the 24 hour Mental Health Crisis Line, available to all residents off Newfoundland and Labrador at 737 4668 or toll free at 1 888 737 4668 or text the Crisis Text Line by texting “TALK” to 686868.

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