Janice Hall 
                                          Registered Psychotherapist 
                                          Reg #002598  

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Consent to Psychotherapy Services Form 
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This form is to document that I/we ____________________ give permission and consent to Janice Hall RP, to provide counselling and/or psychotherapy treatment to me or my child_______________________________________.

Professional Qualifications

I understand that Janice Hall is a Registered Psychotherapist with the College of Registered Psychotherapists.  Registration number: 002598.

Consent for secure online video or phone services

I ___ _____________________________give consent to give permission to Janice Hall to provide counselling and/or psychotherapy via a HIPPA approved video platform or via phone to me or my child: _____________________________.
I understand that reasons for accessing appointments via distance counselling, including but not limited to, physical distancing protocols, a client’s physical or mental health restrictions, a client’s geographic location, inclement weather, etc.  I am aware of the technical risks involved to video services.
I understand that I am prohibited from recording distance counselling sessions (unless I have the written consent of my therapist).  

Benefits of Distance Counselling

-Accessibility and continuity of services

Risks of Distance Counselling

-Technology challenges (i.e. internet connection issues)
-Some presenting concerns may be difficult to address via distance counselling (i.e., suicidal thoughts/ideation, and may require referral to local crisis/emergency services.
-Computer video sessions are the least likely to have connection issues.  If you are using a cell phone and you get an outside call you may need to log back in to the session due to technical issues.
In order to participate in distance counselling, clients must have access to a private space without interruption/distraction in which to engage in services.  Clients must have access to a personal electronic device such as a phone, tablet, or laptop with a reliable camera and microphone for videoconferencing if applicable, and establish with their therapist a backup mode of contact (such as a dedicated telephone line) in case the videoconferencing software is not working effectively.

Nature of Therapy -Risks and Benefits

Psychotherapy is a collaborative process, where the client seeks to improve wellbeing and/or functioning with the assistance of a licensed mental health professional. The licensed professional utilizes their education and experience; however, the ultimate responsibility for improved functioning and wellbeing rests with the client(s).  In addition, wellbeing and functioning are products of a wide-range of factors that may be outside the influence of psychotherapy.  For these reasons, the outcome of psychotherapy cannot be completely guaranteed.
The benefits of psychotherapy include but are not limited to personal growth through goal achievement, development of coping strategies, increased self-awareness, and improvements in interpersonal relationships.  However, risks of psychotherapy include but are not limited to recalling unpleasant events which may lead to strong and/or unexpected changes in feelings, thoughts and mood.  Your psychotherapist will work with you to minimize the risks and maximize the benefits of psychotherapy; however, it is important that you are informed about the risks of psychotherapy.  I welcome any questions regarding your psychotherapists particular therapeutic approach and treatment plan.

Therapeutic Relationship

As your Psychotherapist I can only be your Psychotherapist. I cannot have any other role in your life.  I cannot, now or ever, be a close friend or socialize with any of my clients.  I can never have a sexual or romantic relationship with any client during, or after, the course of therapy.  I cannot have a business relationship with any of my clients, other than the therapy relationship.  
If we happen to meet in public, I will respect your privacy and will not acknowledge you, or in any way disclose the fact that you are my client.  However, you are free to acknowledge me (which I will reciprocate if you initiate) and you are also free to disclose the fact that you are my client to anyone with whom you wish to share that information.

Payment for services

Payment for services is due at the end of each session and a receipt will be given when payment is received.   Fees may be paid by cash, bank etransfer, cheque, VISA, MC or AMEX.  A late payment fee of 2% per month will be added if payment is not received after 30 days of the date of service.  If you have insurance coverage you will pay me first and then submit the invoice to your insurance company for reimbursement.

Insurance Coverage

I understand that counselling services are not covered by the Ontario Health Insurance Plan (OHIP), but are often partially or fully covered by extended health benefit / insurance plans.  I understand that it is my responsibility to verify with my insurer if my policy covers services provided by a Registered Psychotherapist. 

Cancelled and Missed Appointments

Session fees will be applied for appointments cancelled less than 24 hours in advance.
 If the client has an emergency or illness, or is able to reschedule during the same week, cancellation fees will not apply.

Privacy of Personal Information

I understand that my clinical record will be securely kept in a secure site that is double locked. 
I understand that my clinical record will be retained for a minimum of 10 years after the date of my last contact with my therapist, or a minimum of 10 years after my/my child’s 18th birthday if I/my child was under the age of 18 during treatment, after which my clinical record may be destroyed. I understand that all record destruction is completed in a manner compliant with the PHIPA standards to ensure my privacy is maintained at all times. 

Confidentiality

Confidentiality is respected at all times.  No information will be communicated, directly or indirectly, to a third party without your informed and written consent. 
 Exceptions to confidentiality include the legal and/or ethical obligations to:
1.	You have informed me that you may be a danger to yourself, or others
2.	You have informed me of apparent or suspected abuse of a child under 16, or of a person under 16 who is being victimized by someone in a position of power or authority
3.	You have informed me of a known sexual perpetrator that is in close contact with a child under 16
4.	You have informed me of sexual abuse on the part of a health care professional
5.	If my records are subpoenaed by a court of law
6.	If my records or my supervisor’s are audited by a regulatory body (i.e., College of Registered Psychotherapists of Ontario)
As your therapist, I may collect personal information about you.  Your clinical record will be kept securely and will be retained for a minimum of 10 years after the date of your last session or 10 years after you turned 18, after which it will be destroyed.  Should I be contacted by a third-party (medical doctor, lawyer, insurance company etc) I will contact you to get your written consent before releasing any of your records.  

In Case of an Emergency

Emergency services are not available. In the case of an emergency, clients should dial 911, contact their Family Practitioner, or go to the Emergency Department of any hospital.

Office Hours

Office hours are normally 9:00 a.m. to 5:00 p.m. Monday through Thursday.  Some late afternoon or early evening therapy appointments may also be available upon request.  The number of sessions will vary according to need.

Client Discharge

In accordance with the College of Registered Psychotherapists, clients will be discharged from my services and files will be closed after 12 consecutive months if they have not returned since their last therapy session or if they notify me that they will not be returning.   I will notify you in writing of this closure.

Informed Consent

I have read and understood the information presented in this document, and hereby consent to psychotherapeutic treatment.

Fee for services:  $160.00+ $20.80 HST_= $180.80 Total/session

Signature of Client:____________________________________	 

Date:_______________________________________________