I understand that, in accordance with the Privacy Protection Act that my information and treatment is confidential and will not be provided to third parties without my verbal or written consent. The following exceptions to confidentiality are the following:
1) I indicate that I am at imminent risk of harming myself.
2) I indicate that I am harming or at risk of harming others such as a child or vulnerable adult.
3) I am currently being harmed or at risk of being harmed by others.
4) My file is subpeoned to court.
Although not legally required, your therapist will always attempt to have a discussion about these exceptions upfront.
Fees and Attendance:
I understand that the fee for a 60 minute session is $175.
I understand that I am required to pay this fee via e-transfer to email@example.com as soon as the session is completed. If I have Blue Cross, the session will be direct billed to my provider as soon as the session is completed and the remaining balance will be emailed to me. I am required to pay that balance via e-transfer as soon as I receive this email.
I understand that I am required to provide atleast 24 hours notice if I need to cancel my appointment or I may be required to pay the full session fee of $175. If I fail to show or cancel at the last minute I will be required to pay the full amount. Another appointment will not take place until this fee is paid in full.
If you agree to these statements, please sign and date below.