Thank you for choosing Systemic Psychotherapy Ireland (SPI) for your psychotherapy service. The following information and questions are designed to ensure your therapy experience is successful for you. 
Please read this form, in particular the confidentiality statement, and fill in the information requested as best you can. 
If you would prefer not to disclose some, or all, of the information requested that is fine. Please just confirm you have read the confidentiality statement. 
Our approach 
The therapists at SPI have been trained in systemic psychotherapy, also known as family therapy. 
Systemic Psychotherapy recognises that we live our lives in relationships with others, our partners, family members, work colleagues and friends, and that our emotional wellbeing, experience of stress or anxiety, self-image and mental health is greatly influenced by these wider relationships and networks. 
Systemic psychotherapy aims to support people to understand and address their difficulties in the context of other important relationships and events in their lives. 
Systemic psychotherapy is suitable for individuals, couples and family groups, and aims to enhance communication, support people who may have interpersonal difficulties to understand each other’s perspectives, and to find a way to ‘go on’, separately or together. It respects each person’s perspective and experience, and their right to make the best choice for themselves. 
Your therapy goals 
There can be many reasons why people choose to enter therapy. There may be long-term reasons e.g. to improve family relationships and reduce conflict. There may be more immediate needs e.g to decrease anxiety and depression symptoms, changing behaviour or addressing problem drug use. 
It usually takes a few sessions (3 – 4) to establish a strong therapeutic relations and to fully clarify goals. It is recommended therefore that you plan to attend therapy for a minimum of 6 – 8 sessions. 
Your conversation with the therapist, and any information you share, is strictly confidential and no information regarding your attendance or the conversation that takes place will be disclosed to any third party without your agreed, written consent. The legal required exceptions to the above are; 
Where the therapist believes a client, a child, or another person is at risk. 
Where a serious crime is planned or committed 
Where ordered to by a Court of Law. 
Where a client is under the age of 18 both parents/guardians must consent to the therapeutic process. Verbal feedback about the child’s progress will be made to the parent/guardian at agreed intervals. 
Please sign the consent & confidentiality statement here 
It is possible that you and your therapist may meet in a public place. Should this occur, your therapist may protect your confidentiality by not acknowledging you unless you first acknowledge your therapist. 
I understand that my therapist is bound by the Family Therapy Association of Ireland Code of Ethics, which can be read here 
By your signature below, you authorize SPI to contact you by phone and/or text using the number you provide at intake or by e-mail with the address provided. If this is not a safe number or e-mail account to leave messages, please provide a secure means of making contact. 
Payment and cancellation 
Appointments will be pre-arranged. Please inform your therapist of cancellations at least five working days before the scheduled appointment. A full fee will apply if an appointment is not attended and has not been cancelled at least 48hrs in advance. 
Payment can be made by bank transfer, card, cash or revolut. 
Receipts can be issued for health insurance purposes as required. 
Sessions are normally 60 minutes in length. Longer sessions may be arranged as the need arises. 
Please arrive shortly (about 5 minutes) before your scheduled time. 
Please sign the statement of confidentiality & consent here 
If the client is an adult (18 years of age or older) please provide an emergency contact and General Practitioner (Doctor) details 
Emergency Contact 
Doctor Details 
If the client is a child (under 18 years of age) please fill in information on parents/guardians 
Provide contact information here if not listed elsewhere on form: 
You may be required to provide therapist with custody and other legal paperwork needed to ensure therapist has permission by guardians to see client. 
Purpose of Therapy 
Please check all that apply to you and may be a focus of treatment: 
(a child or young person may be supported by a parent/guardian to answer the following) 
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