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Confidential Electronic Consent Form
This form is to confirm in writing that you give permission and consent to Christina Crowe & Associates to provide counselling and psychotherapy services, including consultation, assessment and/or treatment to you and/or your family members.
I consent to the above
Confidentiality & Limits of Confidentiality
information discussed in the process of counselling is held confidential and will not be shared with a third party without the your knowledge and written permission – except where required by law. These situations are limited to the following:
If you threaten imminent serious physical harm to yourself;
If you threaten serious physical harm to someone else;
If you report physical or sexual child abuse (even if the victim is an adult now) if there is reason to believe the accused abuser is in a position to abuse other children;
If you report you have been sexually abused by a health care professional;
If your file is subpoenaed by a court order.
We are located in a small
town! You can be reassured, that confidentiality is very strictly honoured, and Registered Psychotherapists are held to the highest standards as regulated health professionals. We will not acknowledge to anyone that you are a current client, have ever been a client, or have even ever inquired about services. Your therapist will review this with you in person, during your first session.
Crisis/Emergency services are not available
. In case of crisis/emergency, clients should dial 911, contact their family doctor or go to the nearest emergency department of any hospital.
All counselling sessions are 50 minutes in length for individuals and 75 minutes for couples/families.
The fee with
and Clinical counsellors are:
$160 (includes HST)/individuals and
$230 (includes HST) for couples/families.
Payment is due with
session, and may be paid by cash/cheque, debit or credit.
The fees for services from a
$180 (HST exempt)/individual and
$240 (HST exempt) for couples/families.
Rescheduling or cancellation of appointments requires
24 hours notice
. Without such notice, clients could be billed the full session fee.
Illness: If you are ill the day of your appointment, we can keep the time and conduct the appointment by phone/online if that is appropriate given the illness.
Services will be discontinued with written notice for continued non-payment of services. If you are no longer able to continue to pay for services, we will kindly refer you to an appropriate service so that you may continue to receive support. It will be your responsibility to seek care after our services are discontinued.
Unpaid accounts will be referred to a collection agency after 90 days.
Once you are a client, you are welcome to contact your therapist by cell or email as she provides it, and we endeavour to respond within 24 hours. A reminder that email is generally not secure (and becomes part of the client record), and more in depth conversations - in general - should be saved for sessions.
Other commonly asked questions about fees:
Reimbursement by insurance plans depends on the type of plan your employer has selected for you (ask your plan administrator about ‘
If you are covered only for a Registered
, we can still work together; we just need to know
While we are happy to discuss how this works, we are not responsible for the outcome of your claims, nor have details of your particular employer’s insurance plans. We are also authorized ‘medical practitioners’ in Ontario as recognized by the CRA and services
deductible under your medical expenses on your annual tax return.
If you require therapy from a Registered
If you have extended health care benefits for Psychology services, you become Cindy Goodman Stulberg’s client and we, her associates, provide direct counselling services to you.
If you have any questions or concerns regarding our services or those of Cindy Goodman Stulberg’s, you can speak to us directly or to her. She can be reached at 416-736-6809. To maintain your confidentiality, privacy policies are strictly adhered to and are described in the consent to treat form.
Indicates required field
Date of birth (MM/DD/YYYY)
OK to email/leave voicemail?
Comment, if any
Appointment reminders by:
I understand that receipts are emailed in PDF form to my provided email address and are not encrypted. Check the box to allow for emailed receipts (otherwise they can be collected at the following session).
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