CONSENT FOR SERVICES AND CONFIDENTIALITY AGREEMENT FOR A CHILD
Thank you for the opportunity to help you reach your goals. Please read the following carefully, and ask about anything that is unclear. Your signature at the end indicates that you have read and understood the information, and that you agree to the terms of service and payment.
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. We are not responsible for how the contents of your file are interpreted or shared by third parties. Please note that there are limits to confidentiality. In situations where there is knowledge of abuse or neglect of a minor, or imminent and serious risk of harm to your child or others, the therapist is obligated to report this to the authorities. In addition, email communications will always include both parents in order to maintain transparency.
FEES AND PAYMENT
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.
CANCELLATIONS AND MISSED SESSIONS
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.
POLICY FOR PARENTAL DISPUTES, LEGAL PROCEEDINGS AND CPS INVOLVEMENT
The purpose of therapy is growth and healing. When serious conflict occurs between parents, a child is forced into a state of survival thus preventing us from reaching therapy goals. My role as a therapist is to support your child by helping them with problems, behaviors, and difficult feelings; not take sides in parental disputes. I do not get involved in legal disputes, evaluate parent fitness or determine who a child should live with (or other custody matters). These situations are best handled by other professionals who have specialized training in those areas of assessment. Having a therapist involved in court proceedings or providing session notes (on or off record) can harm the therapeutic relationship and the ability to achieve treatment goals.
For confidentiality to remain intact, I request that clients not seek out mental health services with the intention of having me be involved in the court process. If court involvement cannot be avoided and you are a current client, then I prefer that you request a treatment summary if you need documentation. A treatment summary report does not damage the therapeutic relationship, and prioritizes your child’s well being. I prefer that clients or their legal representation not request that I testify or participate in depositions because I do not have that specific training. Please be advised that if disputes arise between parents/guardians involving court, police, or child protective services, your child’s therapy will be paused.
It is important to note that when a therapist is involved in legal proceedings, the courts may request not only the therapist’s clinical opinion, but also their personal opinion. Providing a case summary, allows me to provide the court with a treatment plan and progress, without breaking trust and risking damage to the therapeutic relationship with your child. Unlike mental health professionals, lawyers lack the clinical training to understand the impact of parental disputes on a child. The legal system is often adversarial where one side is expected to win and the other lose. I do not want to participate in that process because I take the therapeutic relationship with your child seriously.
CONDITIONS IF COURT IS UNAVOIDABLE:
Please note that if you insist on involving me in legal proceedings (including a subpoena), you are responsible for the fees. Any time set aside in preparation for a court appearance, preparing of testimony or preparing reports for the attorneys/court, travel, time waiting, dispositions (discovery hearings), paying therapist’s legal fees, etc. will be billed at an hourly rate of $200/hour. Additionally, I will require a retainer of $2000 (equal to 10 hours) as a deposit towards fees for professional time. If time is less than the retainer, the balance will be used as credit towards additional therapy sessions. If time is more than the retainer, the balance will be charged at the end of each day.
The lawyer involved in issuing the subpoena must contact my office at least 4 weeks prior to the court date. My availability is limited to between 9:00 am and 5:00 pm. As mentioned above, court appearance or deposition fees are billed at the rate of $200 per hour. You will be responsible for payment for services in advance. If I am subpoenaed without the appropriate advance notice, you will be billed for all appointments that need to be rescheduled that day as well as any additional legal fees. If the court case is continued, my office is to be contacted within 48 hours in advance or you will be charged for the time reserved by your lawyer.
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 agree that you have read the statements above and agree to comply with the policies listed in this document. You agree that if you do not comply with the policies in this document the counselling relationship with your child may be discontinued.
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. We are not responsible for how the contents of your file are interpreted or shared by third parties. Please note that there are limits to confidentiality. In situations where there is knowledge of abuse or neglect of a minor, or imminent and serious risk of harm to your child or others, the therapist is obligated to report this to the authorities. In addition, email communications will always include both parents in order to maintain transparency.
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.
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.
POLICY FOR PARENTAL DISPUTES, LEGAL PROCEEDINGS AND CPS INVOLVEMENT
The purpose of therapy is growth and healing. When serious conflict occurs between parents, a child is forced into a state of survival thus preventing us from reaching therapy goals. My role as a therapist is to support your child by helping them with problems, behaviors, and difficult feelings; not take sides in parental disputes. I do not get involved in legal disputes, evaluate parent fitness or determine who a child should live with (or other custody matters). These situations are best handled by other professionals who have specialized training in those areas of assessment. Having a therapist involved in court proceedings or providing session notes (on or off record) can harm the therapeutic relationship and the ability to achieve treatment goals.
For confidentiality to remain intact, I request that clients not seek out mental health services with the intention of having me be involved in the court process. If court involvement cannot be avoided and you are a current client, then I prefer that you request a treatment summary if you need documentation. A treatment summary report does not damage the therapeutic relationship, and prioritizes your child’s well being. I prefer that clients or their legal representation not request that I testify or participate in depositions because I do not have that specific training. Please be advised that if disputes arise between parents/guardians involving court, police, or child protective services, your child’s therapy will be paused.
It is important to note that when a therapist is involved in legal proceedings, the courts may request not only the therapist’s clinical opinion, but also their personal opinion. Providing a case summary, allows me to provide the court with a treatment plan and progress, without breaking trust and risking damage to the therapeutic relationship with your child. Unlike mental health professionals, lawyers lack the clinical training to understand the impact of parental disputes on a child. The legal system is often adversarial where one side is expected to win and the other lose. I do not want to participate in that process because I take the therapeutic relationship with your child seriously.
CONDITIONS IF COURT IS UNAVOIDABLE:
Please note that if you insist on involving me in legal proceedings (including a subpoena), you are responsible for the fees. Any time set aside in preparation for a court appearance, preparing of testimony or preparing reports for the attorneys/court, travel, time waiting, dispositions (discovery hearings), paying therapist’s legal fees, etc. will be billed at an hourly rate of $200/hour. Additionally, I will require a retainer of $2000 (equal to 10 hours) as a deposit towards fees for professional time. If time is less than the retainer, the balance will be used as credit towards additional therapy sessions. If time is more than the retainer, the balance will be charged at the end of each day.
The lawyer involved in issuing the subpoena must contact my office at least 4 weeks prior to the court date. My availability is limited to between 9:00 am and 5:00 pm. As mentioned above, court appearance or deposition fees are billed at the rate of $200 per hour. You will be responsible for payment for services in advance. If I am subpoenaed without the appropriate advance notice, you will be billed for all appointments that need to be rescheduled that day as well as any additional legal fees. If the court case is continued, my office is to be contacted within 48 hours in advance or you will be charged for the time reserved by your lawyer.
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 agree that you have read the statements above and agree to comply with the policies listed in this document. You agree that if you do not comply with the policies in this document the counselling relationship with your child may be discontinued.
