Informed Consent

The purpose of this form is to set parameters and guidelines within which this practice functions.  Please read this form before signing at the bottom.
  1. Session Length: Typically One hour. Longer sessions may be mutually agreed upon.
  2. Cancellation or Rescheduling: Both require twenty-four (24) hours advance notification. If cancelled in less than 24 hours, the client will be invoiced for the session (though I reserve the right to not charge). Please help me avoid this situation. I dislike billing for unused time as much as you dislike paying.
  3. Payment of services : My fee is $_____ per session. Billable services include face-to-face and telephone consultations, report writing, and review of written records from other psychologists/therapists/professionals. I reserve the right to charge or waive these fees as well. (No charge for initial telephone in-take or scheduling calls)
  4. Payment is required at the end of each appointment. Cash or cheques are accepted. Regular clients may use E-transfer. I will issue a receipt upon payment.  I cannot carry a balance and will initiate a more formal collection/legal action after 3 mos of non-receipt of payment for a session.
  5. Files: I have the right to review my records in the file at any time, but understand the file belongs to my counselor.
  6. Britannia Bodyworks uses an online scheduler. By entering therapy with _______, I am agreeing that my first and last name, email and phone number are visible to other clinicians in the Britannia office.
  7. I understand that email is not considered a secure communication method. I agree that sessions may be arranged by email. At times I may use email for post or pre-session reflection. I acknowledge the inherent limits of email privacy should I use this tool between session. I acknowledge I will not use email as an alternative to the distress line or the emotional emergency plan I have made for use in case of need in between sessions.
  8. Entering therapy with _____ means we have discussed the limitations and time parameters around my practice and that you understand that I will ask you to use the Distress Centre (403-266-HELP [4357]) or other crisis supports in the case of needing crisis support.
  9. I have explained that I will help you by recommending other therapists should you feel that you prefer a professional who responds to crisis calls or has more frequent office hours.

SIGNATURE BELOW INDICATES THAT YOU HAVE READ AND UNDERSTOOD THE CONTENT OF THIS FORM*:

*I will present an actual form to be signed in my office