ADOLESCENT Consent Form

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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. In starting therapy, you begin a goal-focused process that has a beginning, middle, and end. You have the right to stop therapy anytime. The purpose of meeting with a therapist is to get help with things that you may be struggling with in your life. You may be here because you want to talk to a therapist about one specific issue that is bothering you, or multiple concerns that are negatively affecting your life. Sometimes you will find yourself here because your parent, guardian, doctor or teacher had concerns about you. When you and your therapist meet, you will talk together. Your therapist will ask questions, listen to you, and together you will come up with ideas for dealing with the issues that bother you. It is important that you feel comfortable talking to your therapist about whatever you want. Sometimes discussions will include topics that you do not want your parents or guardian to know about.

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, even if you do not intend to harm yourself or another person, your therapist will use his or her professional judgment to decide whether a parent or guardian should be informed. If you are under 16 and you tell your therapist you are being abused, physically, sexually, or emotionally, or that you have been abused in the past, then your therapist is required by law to report the abuse to the Nova Scotia Department of Community Services. If you and your therapist determine that it would be helpful 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 are involved in litigation of any kind and you inform the Court that you are in therapy, you may be waiving your right to keep your records confidential. If the Court subpoenas your therapist or Acuity Counselling and Therapy Services staff, then your therapist is obligated to appear and to answer questions. 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 are interpreted or shared by third parties.

FEES AND PAYMENT - Fees for our services are $160 or $210 for a 50 minute session, depending on the therapist you see. In addition to therapy and assessment sessions, we bill for other professional services that you ask us to provide such as phone calls and emails which are pertinent to your therapy, reports and letters, case conferences, or meetings. Payment is due prior to the start of each session via credit card. We accept Visa, MasterCard and American Express. Payment is processed on your credit card on the day of your scheduled session and a receipt emailed to you immediately. Occasionally, we may be able to accept payments made by e-transfer, however, we must receive the e-transfer a full 24 hours before the appointment time. Your appointment may be cancelled if your credit card is declined or e-transfer not received 24 hours prior to the session time. If your credit card is declined or payment by e-transfer not received, all future scheduled appointments will be cancelled and no new appointments will be made until the outstanding payment is settled.

CANCELLATIONS AND MISSED SESSIONS - If you need to re-schedule an appointment, please phone ahead (902-406-3400), giving at least 48 hours notice. If you miss an appointment without notice, or cancel a session with less than 48 hours notice, you will be charged the full fee for that session. We understand that sometimes there are unforeseen circumstances, such as illness or inclement weather, which may prevent clients from attending their session. You will not be charged for sessions that are cancelled due to inclement weather or other unforeseen events. If your therapist cancels your appointment, you will not be charged for that session.

INSURANCE – Acuity Counselling and Therapy Services is a private fee-for-service mental health clinic. Our services are not covered under the provincial health care plan (MSI), however, many extended health insurance carriers cover private mental health services. Services may be covered in full or in part by your health insurance provider or employee benefit plan. 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. If you have any questions about insurance or direct billing, please discuss it with our administrative staff. By signing this form, you agree to allow the therapist or billing agent to release information to your insurance provider to process claims.

AGREEMENT - By signing this form you understand that at least 48 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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I consent to receive services *

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PARENT/GUARDIAN FULL NAME *

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I consent to my child/adolescent receiving services *

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