Consent for Treatment

I, the undersigned, hereby consent to receiving Therapeutic Services with the following understandings. This version is intended for virtual counselling. Email is used for scheduling and billing only.

Confidentiality

I understand that all information shared with my therapist is confidential and no information will be released unless I expressly consent to share. All client records (electronic or paper format) will be securely stored.

I further understand that there are specific and limited exceptions to this confidentiality as defined by the law which include the following:

Limits to confidentiality as defined by the law:

• We may share personal health information without consent if it is reasonable to believe that the disclosure is required to prevent or reduce a risk of serious harm to the individual or another individual. This may include contacting relevant authorities even if I do not wish my therapist to do so.
• We must share information with the Department of Social Development regarding any suspicion of neglect or abuse (emotional, physical, or sexual).
• We may disclose your personal health information without your consent when the disclosure is required by law, for example a search warrant.
• If I have elected to see my therapist out of multiple offices, I understand that this requires the physical transfer of my file, which may jeopardize my confidentiality (for example in the case of a vehicle collision or theft). For virtual sessions, records are stored electronically and are not routinely transported between offices.
• In all other requests for my personal information to be either released or obtained by my therapist or other professionals (e.g., my family physician, lawyers, etc.) will be discussed as they arise and will require my written or verbal permission to comply, unless ordered by court.

Attendance

Individual therapy sessions are between 50 and 60 minutes in duration. Session frequency can vary over the treatment period, depending on the specific therapy goal and the progression of treatment.

I agree to inform my therapist 24 hours prior to our appointment time if I need to cancel or change an appointment time. I understand that unexcused no-shows or late cancellations will be automatically billed/charged. An additional $50 fee will be added to the next session and must be paid before re-booking.

Financial agreement

I hereby agree to pay all fees relating to services received by Dimensions of Wellness as well as any third-party collection and legal costs associated with any recovery of amounts outstanding should they occur. I acknowledge that my session fee is:

• Individual Therapy: $150.00 per one hour of face-to-face therapy or virtual therapy
• Couples Therapy: $200.00 per one hour of face-to-face therapy or virtual therapy
• Family Therapy: base fee ($150.00) plus $50.00 per person add-on

Other billable services, such as report writing, professional letters, form completion, and review of written records from other specialists are billed at the same rate. Please verify with your health insurance provider to confirm that my services can be reimbursed by a social worker with a bachelor’s degree. Please note that direct billing is not provided; it will be your responsibility to submit receipts to your insurance provider.

Payment is required at the beginning of each appointment, and I will receive a receipt upon payment. I acknowledge that, should I be unable to remit payment for a session, it will not be possible to book another session until I have paid all outstanding fees.

I accept cash or payment made via e-transfer at pay@dimensionsofwellness.ca for services rendered.

Contacting me / Emergency services

Your messages are picked up on my confidential voice mail. I check my messages periodically and return calls at my earliest convenience.

I do not provide emergency service. If your situation is an emergency or crisis, please contact your local emergency services (Mobile Crisis Response Services 1-866-771-7760, 911, or visit an ER department).

My communications to you via email will be for scheduling and billing only.

Risks and benefits

I understand that while psychotherapy may provide significant benefits based on empirical evidence, it may also pose risks. Psychotherapy may elicit uncomfortable thoughts and feelings or may lead to the recollection of troubling memories. I also understand that choosing not to engage in therapeutic treatment may also result in greater discomfort or escalating risks. It has been explained to me that my feedback and communication about the therapy process and impact is crucial in reducing my risk for harm, and my therapist has encouraged me to communicate any concerns or discomforts with them as soon as is feasibly possible in my treatment. I also acknowledge that therapy is most effective when I am comfortable with my therapist and so, should I not feel comfortable or connected to this therapist I will either request a transfer to another individual or make my concerns known in order to best facilitate care for myself.

Rights and responsibilities

It is your clinician’s responsibility to treat you with respect and to provide clear information about treatment and treatment options. It is also my responsibility to participate fully during sessions, to complete assigned homework, to practice new skills and to actively work towards achieving my goals.

I understand that services are voluntary and that I have the right to terminate services at any time.

I understand that this consent will remain in effect until such a time as I withdraw it via written consent or discontinue services with my therapist by informing them of my intent to do so.

Respectful behavior is expected at all times, and I understand that disrespectful or aggressive behavior will not be tolerated and that services may be terminated.

I have had the opportunity to discuss the limits of confidentiality as well as all aspects of this treatment agreement and I understand and agree with the treatment conditions listed above.