ADOLESCENT Consent Form

ADOLESCENT CONSENT FOR SERVICES AND CONFIDENTIALITY AGREEMENT

WELCOME
Thank you for choosing Acuity Counselling and Therapy Services Inc. Please read the following carefully. Your signature indicates that you understand and agree to these terms.

THERAPEUTIC RELATIONSHIP
Therapy is a space to talk openly about what matters to you. Your therapist will listen, ask questions, and help you explore strategies for dealing with challenges. It is normal for some conversations to include topics you may not want your parent or guardian to know about. Your privacy will be respected within the limits of confidentiality described below.

CONFIDENTIALITY
Your therapist will not share information with your parent/guardian unless you give permission, except in situations where they are legally required to act. These situations include:

A risk of serious harm to yourself or someone else
Disclosure of past or present abuse (physical, sexual, or emotional)
A court order requiring information

Whenever possible, your therapist will involve you in the process of deciding what information needs to be shared. If you request that information be shared with another party (e.g., your physician), you will be asked to sign a consent form. If you request a letter or copy of your file, you will have the opportunity to review the contents before it is released.

FEES AND PAYMENT

Session fees range from $190–$225 depending on the therapist.
Payment is due on the date of your appointment.
To ensure compliance with insurance requirements and to protect your appointment time, payment is processed on the day of your scheduled session, prior to the start of the session.
A receipt will be emailed to you on the same day.

If payment cannot be processed, you will receive a private notification. If payment is not completed by 10:00 AM, the appointment is automatically cancelled and released to another client. If more than one declined payment occurs within a 12‑month period, direct billing privileges may be discontinued, and you may be required to pay the full session fee before each appointment and submit receipts to your insurer.

Parent/Guardian Financial Responsibility
Parents/guardians are financially responsible for all appointments booked for or by their adolescent, including:

Sessions the adolescent books independently
Late cancellations and missed appointments
Outstanding copays and declined payments
Future appointments cannot be held if a balance or copay remains outstanding

CANCELLATIONS AND MISSED SESSIONS

Cancellations with less than 24 hours’ notice are charged 100% of the session fee.
Missed appointments are also charged 100% of the session fee.
Insurance does not cover late cancellation or missed appointment fees.
These fees must be paid before additional appointments can be booked.

Reminder emails are sent 48 hours before your appointment. Please note that reminder emails are a courtesy only and it is ultimately YOUR responsibility to remember your scheduled appointments. The cut‑off for Monday cancellations is Friday at 1:00 PM.

INSURANCE
Our services are not covered by MSI, but many extended health plans provide coverage. It is your responsibility to understand your plan, including copayments, deductibles, and session limits. We offer direct billing for most Blue Cross plans and some federal/provincial programs. Direct billing is a courtesy service and may be discontinued if payment issues occur. Insurance requires that copays be collected on the date of service. If a copay cannot be paid, we are unable to bill insurance, and the appointment must be cancelled. If your insurance does not cover the full cost of the session, you are responsible for the remaining balance.

AGREEMENT
By signing below, you acknowledge and agree that:

You understand the 24‑hour cancellation policy.
You agree to pay for late cancellations and missed sessions.
You authorize Acuity Counselling to charge your credit card for session fees and applicable cancellation fees.
You authorize the release of information to your insurance provider for the purpose of processing claims.
You agree to pay any portion of the session fee not covered by insurance.
You understand that payment is processed on the morning of your appointment and that your appointment may be cancelled if payment cannot be completed.
You understand that direct billing is a courtesy and may be discontinued if payment issues occur.
You understand that parents/guardians remain financially responsible for all appointments booked for or by the adolescent
You have read, understood, and agree to the information in this form.

* Indicates required field

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

SUBMIT