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. I understand that I will, typically, not get a reminder call for my appointment.
  7. I understand that email is not considered a secure communication method. I agree that sessions may be arranged by email.
  8. 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.
  9. 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.
  10. 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.


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