ADOLESCENT Consent Form

ADOLESCENT CONSENT FOR SERVICES AND CONFIDENTIALITY AGREEMENT

Thank you for the opportunity to help you reach your goals. Please read the following pages carefully, and ask about anything that is unclear. Your signature at the end will indicate that you have read and understood the information, and that you agree to the terms of service and payment.

COUNSELLING RELATIONSHIP - Our goal is for you and your therapist to work together as a team. Your therapist will expect you to be actively involved in the therapeutic process as you work toward your goals. You have the right to ask your therapist about treatment methods so you can make informed decisions about what methods are most suitable for you. You have the right to stop therapy anytime. Your therapist will ask questions, listen to you, and together you will come up with ideas for dealing with the issues that bother you. Sometimes discussions will include topics that you do not want your parents/guardian to know about. It is important that you feel comfortable talking to your therapist about whatever you want.

CONFIDENTIALITY - What you disclose during the therapy sessions is kept in strict confidence. Information is only released with your expressed consent except when mandated by law/court (i.e. subpoena) or a risk of harm to yourself or others is expressed. If you are doing things that could cause serious harm to you or someone else, your therapist will use their professional judgment to decide whether a parent/guardian should be informed. If you tell your therapist you are being abused, physically, sexually, or emotionally, or that you have been abused in the past, your therapist is required by law to report the abuse to the Nova Scotia Department of Community Services. If you wish to share information about your therapy with someone else (e.g., your physician), then your therapist will ask you to sign a form that gives Acuity Counselling and Therapy Services permission to release and/or request information. If you request a letter or copy of your file to be sent to a third party, you will be offered an opportunity to review the contents before it is released. We are not responsible for how the contents of your file are interpreted or shared by third parties.

FEES AND PAYMENT - Fees for our services are $190 or $225 for a 50 minute session, depending on the therapist you see. Payment is due prior to the start of each session via credit card. Payment is processed on the day of your scheduled session and a receipt emailed to you or your legal guardian on the same day. Your appointment may be cancelled if the credit card is declined, all future scheduled appointments will be cancelled and no new appointments will be booked until the outstanding payment is settled.

We require a minimum of 24 hours notice to cancel or reschedule an appointment. Reminder emails are a courtesy only and it is ultimately YOUR responsibility to remember your scheduled appointments.

CANCELLATIONS AND MISSED SESSIONS - Please contact us (902-406-3400) as soon as possible to cancel or reschedule. If you miss an appointment or cancel a session with less than 24 hours notice, you will be charged 100% of the fee for that session. Please note that emails for appointments are generally sent out 48 hours before your scheduled appointment in order to allow for our 24 hour cancellation policy. The cut off for a Monday cancellation is Friday at 1pm. Please ensure the front desk has your email address to receive reminder emails.

INSURANCE – Our services are not covered under the provincial health care plan (MSI), however, many extended health insurance carriers cover private mental health services. Please check your coverage carefully by calling your insurance provider prior to setting up an appointment. It is your responsibility to understand the parameters of your insurance policy and keep track of your coverage including any co-payment and number of sessions covered. We are able to process direct billing for most Blue Cross plans, and some federal/provincial agencies.

AGREEMENT - By signing this form you understand that at least 24 hour notice needs to be given to reschedule or cancel an appointment. You agree to participate in the therapy process with Acuity Counselling and Therapy Services Inc. and that the therapy process is collaborative. You understand that information about you is confidential and understand the limits to confidentiality. You agree to pay for missed sessions and short-notice cancellations, and understand that your credit card will be charged for the fee of a full session. You agree to allow us to release information to your insurance provider to process claims. You have read, understand and agree to the information on this form.

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Name *

First

Last

I consent to receive services *

Yes No

PARENT/GUARDIAN FULL NAME *

First

Last

I consent to my child/adolescent receiving services *

Yes No

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