Consent Form | Psychology

Psychology Consent Form

First name

Last name

Birthday

Phone

Address

Where Would You Prefer To Be Contacted?

May We Leave A Message For You At These Numbers

Yes

Family Physician:

Telephone

Address:

Insurance Company (If Applicable):

Referral Source:

Name Of Person To Contact In An Emergency:

Relationship:

Phone

Address

Today’s Date:

Private Practice Consent Statement

These Terms and Conditions are Mandatory .

Please Read them Thoroughly and Carefully then Submit.

I agree to be seen in the private practice at Clue Academy Psychology Sessions.

I understand that I will be seen by Samira Rostami, who is licensed and registered with

the College of Registered Psychotherapists of Ontario (CRPO).

I have been provided with information that describes the services provided by my

psychotherapist through phone consultation, websites, or email, including an overview of

the assessment and treatment procedures and services that will likely occur and I consent

to treatment, with the understanding that I may terminate these services at any time.

Confidentiality and Privacy Policy

I understand that my psychotherapist will not disclose information that has about me

(including all information contained in your clinical file), directly or indirectly, to any

third party without my informed and written consent, except when my psychotherapist is

under one of the following legal obligations to release confidential information:

• If your psychotherapist believes that you are an imminent danger to yourself or to

someone else, she is required to contact the authorities, people who can intervene to

help prevent harm to you or others, and any intended victims of harm.

• If your psychotherapist suspects or is informed that a child is at risk of being harmed

in any way (e.g., sexual or physical abuse, negligence) she must contact the

Children’s Aid Society and report all relevant information.

• If your information gets subpoenaed by a court, your psychotherapist is entitled to

release your information to the court.

• If the College of Registered Psychotherapists of Ontario requests access to files to

assure the quality of care, we are obligated to allow them that access. The Colleges

are bound by their own strict confidentiality rules.

5. I have had the chance to review the Privacy Policy about the collection, use, and

disclosure of my personal information and my personal health information, the steps

taken to protect the information, and my right to review the information. I understand

how the privacy policy applies to me. I have been given a chance to ask questions that I

may have about the Privacy Policy and they have been answered to my satisfaction.

The fee for each 50-minute session is $195 (subject to change).

Cancelled or Missed Appointments

If you wish to cancel a session, you are entitled to inform your psychotherapist 24 hours

before your session. Otherwise, you will be charged the full amount of the session fee.

I hereby confirm that I have read, understood and accept the above information.

I also confirm that I will NOT commit suicide or any other act of self-harm until I decide that I no longer wish to continue my psychotherapy sessions with my psychotherapist,

Samira Rostami, Registration Number: 7806.

+1 (647) 289-0101

4 Church St. S, Richmond Hill

Mon - Sat: 9:00 - 22:00

Psychology Consent Form

Private Practice Consent Statement