Client Consent to Treatment
You must have read and consented to the following prior to commencing treatment. Digital submission of consent requires completion of the ‘Agreement’ section at the bottom of this screen. Please ‘check’ the box above the submission button.
Hours of Service
All services are provided through a secure, online, video platform. Appointments are available Tuesday and Thursday at 10:00 a.m., 11:30 a.m., 2:00 p.m., and 3:30 p.m. Appointments are typically one hour in length.
I acknowledge that I have read and understand the Teletherapy Checklist:
Teletherapy Checklist (Click the Arrow to Expand)
Payment for Services
One hour appointments are $150. Payment may not be deferred and is due on a session by session basis. Extended health benefits may be utilized where benefit plans are supported for treatment by a psychologist. Motor vehicle accident benefits are supported, following an initial appointment; and approval of a treatment plan.
Patients rostered with the Stratford Family Health Team, who do not have access to coverage through the foregoing, may complete an intake interview with the Health Team’s intake coordinator to be considered for up to six funded appointments in the twelve month period following.
Cancelled or Missed Appointments
Should you be unavailable for a scheduled appointment, notification via email (firstname.lastname@example.org) is required a minimum of 24 hours in advance to avoid a default charge equivalent to one session. Emergency circumstances will reasonably be taken into account.
Confidentiality / Consent
Confidentiality is respected at all times. By signing this information form, you affirm your understanding that the sole exceptions to the maintaining of this confidence are those listed below; and constitute the practitioner's legal obligation to:
- Inform a potential victim of a client's intent to harm them.
- Ensure the safety of a client who intends to end his/her life.
- Inform the Children's Aid Society if revealed that a child is at risk for sexual or physical abuse.
- Report a health professional who has sexually abused a client.
No information will be communicated, directly or indirectly, to a third party without informed and written consent.
In Case of Emergency
Please notify via email; and attend area crisis services, hospital emergency, family physician as appropriate.
Please fill out the following information, check the box showing that you have read and understood the information presented, and click the [I Consent to the Above Statements] button.