General Informed Consent Form

Treatment:

Based on the results of an initial assessment, clients will be provided with treatment options.

• Family therapy
• Individual therapy
• Group therapy

Confidentiality:

• All information obtained during treatment will be kept in a locked filing cabinet in the Compass for
• Life Office or on Owl Practice Management's secure PHIPPA compliant website
• No information obtained during the treatment will be discussed or released to anyone else (e.g., family doctor, child's school, employer) without the client's written consent.
• Limits of confidentiality:
  • Therapists are required by law to report:
    • situations where a client threatens to harm self or others
    • suspicion of child abuse or neglect
  • Therapists are required to provide confidential information to the court if this information is subpoenaed. The therapist may make a plea not to do so, but this may or may not be upheld by a judge.

Cancellation and missed appointments policy:

• You will be charged the full amount for any session that is missed with less than 48 business hours notice.
• Any session for which you/your child is more than 20 minutes late will be considered a missed session.
• Fees for missed sessions will be waived under certain circumstances:
  • Significant medical illness, documented by a doctor’s note
  • And emergency in the immediate family

Electronic Communication:

The use of electronic communication is used primarily for the purpose of billing and coordinating contact. The transmission of information via email or text may unintentionally limit the protection of confidentiality. More specifically, networks are not secure, emails are not encrypted and emails can be sent to unintended recipients without the sender’s intent. Given these risks, I agree to use email to communicate for billing and the purpose of coordinating contact.

Authorization to Receive Therapy Using Remote Therapy Services:

• There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions. It is your responsibility to ensure your confidentiality when engaging in online therapy at your home, work, school, or other environments
• It is strongly recommend that you choose a secure space while participating in remote therapy and that you ensure that no recording devices have been turned on, either by you or someone else (i.e. friend, family member)
• Confidentiality still applies for remote therapy services, and nobody will record or share the session without the permission from the others person(s)
• The use of a webcam or smartphone during the session is require
• Headphones are strongly suggested and help improve privacy and quality of the call It is important to be in a quiet, private space that is free of distractions (including cell phones or other devices
• 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 appointment, you must notify me 2 business days in advance by phone or email, as you would for a regular session.
• doxy.me will be the secure video service used. An invitation or link will be sent prior to the initial call by text or email. A phone number is required as backup in case of technical difficulties. I consent to the use of alternative services like Face Time, Skype or What's App with the knowledge that they do not offer the same degree of security as doxy.me and are not HIPA or PHIPA compliant at this time.

Counseling Fees:

• Initial appointments/assessment fees are billed at a rate of $375.00 for 1.5 hour session and $250 for 60 minutes 
• Subsequent clinical time is billed at a rate of $210.00 per 50 minute clinical hour. Longer sessions will be prorated accordingly (including school consultations, phone meetings, written letters, meetings with allied professionals etc.)
• Please note that a clinical hour is 50 minutes face to face with 10 min. for administration
• Payments method will include Visa, and MasterCard that will be stored securely with Stripe
• Balances that remain unpaid 30 days past notice of receipt will be subject to a 3% administration fee
• Balances that remain unpaid 90 days past notice of receipt will be subject to external collections

Fee and Late Payment Policy:

• Initial Appointment fee is $375 (90 minutes) and subsequent individual session fees and clinical time are billed at a rate of $210. Please refer to the chart below for a detailed outline of fees.
• Session fees are due at the end of each session and payable by credit cad on file. (Stripe uses the secure PCI Hosting Provider. Stripe is a trusted Level-1 PCI Compliant provider (that’s the highest level of security and compliance). Please refer to the following link for more information. https://stripe.com/docs/security/stripe
  
• Balances that remain unpaid 30 days past due will be subject to a 3% administration fee.

Fee Schedule Breakdown: