Consent Form

INFORMED CONSENT FOR PSYCHOTHERAPY SERVICES

This consent form is to document that I/we give permission and consent to Nikki Goldman-Stroh, to provide psychotherapy services to myself or my child.

Psychotherapy may involve benefits and risks and I will discuss any of my concerns during the process.

1. Confidentiality Confidentiality is respect at all times and no information will be released to a third party without my informed consent, with the following exceptions:

• If a patient is considered to be an imminent threat to her or his physical safety or to the safety of others.

• If there is suspicion of child abuse or neglect, the appropriate child welfare authorities will be notified.

• If a patient has been sexually abused by another member of the same or a different regulated health profession.

• If a court orders disclosure of records.

2. Records We require by law to maintain records of each visit and will be confidentially maintained for 10 years following termination as per the laws.

3. Fees and Payment: The fees for services vary depending on rate that is offered. Please note that KIDCREW sessions are $180 plus HST. Please email info@seasonsfamilycentre.com to confirm rate for private sessions.

All payments are collected at the time of service. Payments must be made by check, cash or email transfer at time of the session. Fees may vary according to the time and nature of the service(s) involved (e.g report writing will be billed at your regular appointment fee; telephone conversations in excess of 15 minutes will be billed at your regular appointment fee, in quarter hour increments; and consultation with other professionals will be billed at your regular appointment fee, in quarter hour increments) and you will be advised in advance if any changes are made to the fee. A surcharge of $25.00 will apply to all N.S.F cheques. A late fee of 2% per month will be added if payment is not received after 30 days of the date of service. Outstanding accounts of more than 30 days will be eligible for submission for collection.

4. Cancellation There is a 48-hour cancellation policy. If you cannot attend your appointment please notify me 48 hours in advance, otherwise you will be charged the full amount of the missed session.