Client Consent to Treatment

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 typically one hour in length.

Teletherapy Checklist

I acknowledge that I have read and understand the Teletherapy Checklist:

Teletherapy Checklist (Click the Arrow to Expand)

Teletherapy Checklist

• There are potential benefits and risks of video-conferencing (e.g., limits to client confidentiality) that differ from in-person sessions.
• Confidentiality continues to apply for teletherapy services; and sessions will not be recorded without the knowledge and consent of both parties.
• We agree to use the video-conferencing platform selected for our virtual sessions, and the therapist will explain how to use it.
• You need to use a webcam or smartphone during the session.
• It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
• It is important to use a secure internet connection rather than public/free Wi-Fi.
• It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the therapist in advance by email.
• Back-up plan is arranged (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
• We need a safety plan that includes at least one emergency contact and the closest ER to your location, in the event of a crisis situation.
• You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.

Payment for Services

One hour appointments are $200. 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.

Cancelled or Missed Appointments

Should you be unavailable for a scheduled appointment, notification via email (david@davidhowardpsychologist.com) 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.

Agreement

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.