Carlen Costa , DHS, RSSW, ACS
Clinical Sexologist & OCSWSSW Psychotherapist
Client Confidentiality and Terms of Service
Background & Training
Carlen Costa received her Masters in Public Health and a Doctorate of Human
Sexuality from the Institute for the Advanced Study of Human Sexuality. She is
registered with the American College of Sexologists, The Society for the Scientific Study
of Sexology, subscribes to the Sex Information and Education Council of Canada, is a
Cannabis Educator registered with the Sativa Science Club and is a registered
Psychotherapist with the Ontario College of Social Workers and Social Service Workers.
All information disclosed within sessions and the written records pertaining to those
sessions are confidential and may not be revealed to anyone without your (client’s)
written permission, except where disclosure is required by law.
When Disclosure Is Required By Law:
Some of the circumstances where disclosure is required by the law are:
-where there is a reasonable suspicion of child, dependent or elder abuse or neglect
- where a client presents a danger to self, to others, to property, or is gravely disabled
- when client’s family members communicate to Carlen Costa, that the client presents a
danger to others.
When Disclosure May Be Required:
Disclosure may be required pursuant to a legal proceeding by or against you wherein
the right to obtain the therapy records and/or client notes be in use of subpoena.
In relationship therapy and Sexology, or when different family members are seen
individually, even over a period of time, confidentiality and privilege does apply between
the couple or among family members, unless otherwise agreed upon. Carlen Costa, will
use her clinical judgment when revealing such information and will generally do so with
the guidance of the referenced client. Carlen Costa, will not release records to any
outside or third party unless she is authorized to do so by the specified client with
Health insurance & confidentiality of records:
Disclosure of confidential information may be required by your health insurance carrier
in order to process the claims. If you instruct Carlen Costa, only the minimum necessary
information will be communicated to the carrier. Carlen Costa has no control or
knowledge over what insurance companies do with the information she submits or who
has access to this information. You must be aware that submitting an invoice for
reimbursement carries a certain amount of risk to confidentiality, privacy or to future
capacity to obtain future benefits. Carlen is a registered health provider in good standing
Due to the nature of the therapeutic process and the fact that it often involves making a
full disclosure with regard to many matters which may be of a confidential nature, it is
agreed that should there be legal proceedings (such as, but not limited to divorce and
custody disputes, injuries, lawsuits, etc..), neither you (client) nor your attorney’s, nor
anyone else acting on your behalf will call on Carlen Costa, to testify in court or at any
other proceeding, nor will a disclosure of the therapy records/client notes be requested
unless otherwise agreed upon.
Carlen Costa consults regularly with other professionals regarding her clients; however,
client’s identity remains completely anonymous, and confidentiality is fully maintained.
This is in order to provide you with the best and well rounded service that can be
E-Mails, Cell phones, Computers and Faxes:
It is very important to be aware that computers and e-mail and cell phone
communication can be relatively easily accessed by unauthorized people and hence
can compromise the privacy and confidentiality of such communication. E-mails, in
particular are vulnerable to such unauthorized access due to the fact that servers have
unlimited and direct access to all e-mails that go through them. Carlen Costa’s e-mails
are not regularly encrypted but can be if the patient requires it. Carlen Costa’s
computers are equipped with a virus protection and a password.
Please notify Carlen Costa, if you decide to avoid or limit in any way the use of any or all communication devices, such as e-mail, cell-phone or faxes. Please do not use e-
mail or faxes for emergencies.
Records and Your Right to Review Them:
Both the law and the standards of Carlen Costa’s profession require that she keeps
appropriate treatment records for at least 7 years. If you have concerns regarding the
treatment records please discuss them with Carlen Costa. As a client, you have the right
to review or receive a summary of your records at any time, except in limited legal or
emergency circumstances or when Carlen Costa, assesses that releasing such
information might be harmful in any way. In such a case Carlen Costa, will provide the
records to an appropriate and legitimate mental health professional of your choice.
Considering all of the above exclusions, if it is still appropriate, upon your request,
Carlen Costa will release information to any agency/person you specify unless Carlen
Costa assesses that releasing such information might be harmful in any way. When
more than one client involved in treatment, such as in cases of couple and family
therapy, Carlen Costa, will release records only with the signed authorizations from the
specified client (or all those who legally can authorize such a release) involved in the
TELEPHONE & EMERGENCY PROCEDURES:
If you need to contact Carlen Costa, between sessions, please leave a message on the
answering service and your call will be returned as soon as possible. Carlen Costa
checks her messages a few times during the daytime only, unless she is out of town or
otherwise incapacitated. If an emergency situation arises, indicate it clearly in your
message and if you need to talk to someone right away, call your local emergency or
dial 911. Please do not use e-mail or call for emergencies. Carlen Costa does not
always check her e-mail or messages daily.
PAYMENTS & INSURANCE REIMBURSEMENT:
Clients are expected to pay the standard fees outlined in the Payment Schedule, as
agreed upon by said client and Carlen Costa as follows:
For in-office sessions, clients are expected to pay upon booking, the standard fee of
$200.01 per 50 minute session prior to each session or unless other arrangements have been made. Other arrangements will require a second agreement to be signed by Carlen Costa and the respective client(s).
By clicking the box on the sales page, I agree agree to the terms as set out by Carlen Costa’s payment agreement schedule.
Failure to provide payment will result in full termination of service and notice by an initial warning letter or communication and
may result in the involvement of a collection agency.
I agree to the fees and understand they are non-refundable.
Record of attendance will not only be solely the responsibility of Carlen Costa, but also
the responsibility of the aforementioned client to ensure signature of the proper