Intake Form for Psychotherapy Services

Attached as a PDF below is the form that all clients are required to fill out prior to beginning psychotherapy.  It informs you of: 

-the nature of the services you receive

-your rights and obligations as a client receiving services from me, including fees and payment for services  

-my responsibilities to you as your psychotherapist  

*It is important for you to review and send this form ahead of your initial session. I also encourage you to ask any questions about your psychotherapy and this form prior to your first appointment.  This will ensure that you are provided with informed consent.  

For in person sessions, I also have copies at the office if needed.   


Fees  for Psychotherapy and Clinical Consulting Services  

Current Fee Schedule

In addition to the current rates listed below, provincial and federal governments require HST to be billed for all services. 

Payment methods accepted: interac money transfer, cheque or cash. 

Payment due prior to session or service unless alternate arrangement made in advance.

Individual Psychotherapy/Couple Counselling and Family Therapy:  $135/hr plus HST (17.55/hr) (Psychotherapy sessions are 1 hour minimium.  Longer sessions can be arranged.  Subsequent time is billed by the 1/4 hour per session). I have limited sliding scale spots available for those who require them.  Please inquire if needed to determine availability.

Phone or video conferencing sessions may be scheduled in advance for as little as 1/2 hour, with additional time billed by the 1/4 hour as required and available. 

Clinical Supervision and Consultation: $135/hr plus HST for individuals and organizations (plus expenses, if applicable).

Group Counselling: Please inquire.

Workshops and Educational Services: Please inquire. 

Organizational Program Development and Supervision:  to be negotiated with agencies.  Please inquire.

  

General Payment Policies 

All services are based on a fee for service and are to be paid by the client prior to or at the beginning of each scheduled session or consultation.   Any exception to this payment policy must be arranged in advance.  

CANCELLATION POLICY FOR PSYCHOTHERAPY AND COUNSELLING SESSIONS  

When you book a session you are booking and reserving that time specifically for you.  As such, please note that at least 24 hours notice of cancellation needs to be provided for all psychotherapy and counselling appointments or you will be required to pay the full fee for the missed session.

Possible Sources for Funding or Reimbursement of Fees for Psychotherapy Services

For psychotherapy and counselling services, clients may have access to reimbursement, either partially or wholly, through health insurance plans and employee benefits that cover the owner of the policy or the employee with benefits as well as the other people designated under their plans.     Please note that you are required to pay your session fee at the time of your appointment and it is your responsibility to follow up with your benefits provider for reimbursement.  

If you do not have coverage and are required to cover your own costs for psychotherapy, then it may be useful to note that psychotherapy and counselling services are often tax deductible and you can claim them as a medical expense on your tax return.   

If either situation is the case for you, please request a receipt for this purpose. 


Additional Resources:  There are also government funded sources that may be accessed from programs that have been developed to provide financial assistance to various populations such as victims of crime.  By applying for these funds, you often have access to money that may be utilized to pay for psychotherapy sessions related to healing from injuries sustained.  

   Depending on the circumstances of your situation, the costs of mental health services may also be covered by WSIB and extended insurance policies that cover mental health services resulting from injuries sustained in the workplace.   Similarly, insurance coverage for automobile and other insured properties may cover mental health fees in order to assist those who are suffering, directly or indirectly, as a result of trauma and injuries sustained. 


Check out your resources to determine if there is coverage for mental health services for your specific needs.  


 

 

AAAA2020-21 PP Intake Form.pdf AAAA2020-21 PP Intake Form.pdf
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Type : pdf