Request for service

Confidentiality

What we discuss is confidential and remains privileged information. I will not release information about you without your informed and written consent, except in the following circumstances:

• If a child may have been harmed in the past, or that a child is at risk of harm in the present or future, I have a duty to report this.
• If there is risk of harm to yourself or others.
• If I am required by law to do so, such as a court subpoena.
• If I am bound by law to report a regulated health professional for
  professional misconduct.
• If an individual becomes incapacitated and I need to contact a family member, friend or substitute decision maker.

Privacy of personal information

I take notes to help me keep track of the issues that arise during the course of our work together. I have a duty to protect the collection, use and disclosure of this information, which is by law considered your “personal health information”. When it is time for your records to be destroyed, I will do so in a secure way that protects your confidentiality.

Videoconferencing

I offer online services. This is a relatively new way of conducting counselling and while there is good evidence to support its usefulness and benefits, there are associated risks and challenges. Risks include the fact that the technology may be compromised, unresponsive and slow at times. Benefits include not having to travel and more efficient use of time. While most insurance companies have provided coverage for virtual psychotherapy for a number of years, it’s always best to check with your provider. The software I use is encrypted in order to protect your privacy and meet provincial requirements for personal health information.

There are a number of things you can do on your end to ensure your privacy:

Ensure that the device you use is private and you have shut off any other possible ways for someone else to connect, such as Bluetooth device that connects in a shared car. When we connect, ensure that you are in a private room. If someone else is present, you must tell me, and they will need to be on camera. If for some reason our technology fails, I will telephone you at the number specified above.

Neither you nor I may make audio or visual recordings of a session without mutual and legal consent.

I agree to the use of videoconferencing*

I understand the risks, challenges and benefits of videoconferencing and the expectations for both the psychotherapist and the client. I am aware of the measures taken to secure and protect the use of confidential information.

Cancellation of appointments

I require twenty-four (24) hours’ notice via text, email, phone or voicemail or I will be obliged to charge you for the missed appointment.

Professional fees

Payment is due at the end of each session and can be made by cash, cheque or electronic bank transfers. I do offer sliding scale fee. If you are interested in discussing this, please let me know.

Your rights as a client receiving counselling services
I am committed to providing services in a professional, respectful and ethical manner. I would encourage you to discuss with me any concerns you may have in the delivery of this service.

By checking the box below you agree that you have received and that you understand the above-stated information.

Confidentiality
What we discuss is confidential and remains privileged information. I will not release information about you without your informed and written consent, except in the following circumstances:

• If a child may have been harmed in the past, or that a child is at risk of  harm in the present or future, I have a duty to report this.
• If there is risk of harm to yourself or others.
• If I am required by law to do so, such as a court subpoena.
• If I am bound by law to report a regulated health professional for
  professional misconduct.
• If an individual becomes incapacitated and I need to contact a family member, friend or substitute decision maker.

Privacy of personal information
I take notes to help me keep track of the issues that arise during the course of our work together. I have a duty to protect the collection, use and disclosure of this information, which is by law considered your “personal health information”. When it is time for your records to be destroyed, I will do so in a secure way that protects your confidentiality.

Videoconferencing
I offer online services. This is a relatively new way of conducting counselling and while there is good evidence to support its usefulness and benefits, there are associated risks and challenges. Risks include the fact that the technology may be compromised, unresponsive and slow at times. Benefits include not having to travel and more efficient use of time. While most insurance companies have provided coverage for virtual psychotherapy for a number of years, it’s always best to check with your provider. The software I use is encrypted in order to protect your privacy and meet provincial requirements for personal health information.

There are a number of things you can do on your end to ensure your privacy:

Ensure that the device you use is private and you have shut off any other possible ways for someone else to connect, such as Bluetooth device that connects in a shared car. When we connect, ensure that you are in a private room. If someone else is present, you must tell me, and they will need to be on camera. If for some reason our technology fails, I will telephone you at the number specified above.

Neither you nor I may make audio or visual recordings of a session without mutual and legal consent.

I agree to the use of videoconferencing*

I understand the risks, challenges and benefits of videoconferencing and the expectations for both the psychotherapist and the client. I am aware of the measures taken to secure and protect the use of confidential information.

Cancellation of appointments
I require twenty-four (24) hours’ notice via text, email, phone or voicemail or I will be obliged to charge you for the missed appointment.

Professional fees
Payment is due at the end of each session and can be made by cash, cheque or electronic bank transfers. I do offer sliding scale fee. If you are interested in discussing this, please let me know.

Your rights as a client receiving counselling services
I am committed to providing services in a professional, respectful and ethical manner. I would encourage you to discuss with me any concerns you may have in the delivery of this service.

By checking the box below you agree that you have received and that you understand the above-stated information.