Therapy Intake Form

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Welcome to Julia Ryan Psychology

Thank you for your interest in working with us. Before you begin, please review the following information regarding our therapy intake process.

Time Commitment

This is an intake package that includes consent for service, reason for seeking service and relevant background information. It takes about 20 minutes to complete this form from start to finish. 

Please ensure you have a stable internet connection and set aside the required time to fill out this form. Your progress will be lost if you exit this webpage before submitting.

We also recommend you fill out this form on a device with a screen larger than a phone, but it is not strictly necessary.

Timeline

You'll hear back from us within 2 business days of submitting this form. During that time, our intake coordinator will review your form submission to determine who among our available clinicians would be a good match. You will get the opportunity to request to work with a specific clinician or to prioritize lowest cost.

Once our initial review is complete, we'll email you to discuss next steps.

Waitlist

We do not keep a waitlist for therapy. If we are unable to offer you a clinician suitable to your needs now, we will offer referral options.

Ages Currently Open for Therapy

Therapists are currently available for {ageRangeString}. 

Your Information

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Client Information

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Throughout this form, the individual to receive therapeutic services will be referred to as the Client.

The information below will be used to create the Client's official file. Please enter the details (name, date of birth, etc.) for the individual who is receiving the services.

If you are submitting this form for someone else, do not use your own name or date of birth in these "Client" fields. Doing so will create an incorrect file and will require us to resend the form for correction.

Informed Consent

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Instructions

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The next several sections of the form contain important information about the services that are offered by Julia Ryan Psychology. As a clinic providing regulated health services, it is required that you provide informed consent.

We value your privacy and take active measures to protect the Client's personal health information. Due to these protective measures, your progress is not automatically saved. Your progress will be lost if you exit this webpage before submitting.

Please read this information carefully to make sure that you understand it. 

Contact Us

If you have any questions about this form, we encourage you to reach out to us.

You can contact the clinic at 613-699-0825 or admin@drjuliaryan.ca if you have questions about the information in this form while completing it.

Therapy Overview

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Therapy (also referred to as intervention) is a collaborative, goal-oriented process that supports individuals in understanding themselves, strengthening skills, and making meaningful changes in their lives. Therapy is tailored to each person’s unique needs, strengths, and developmental context, and may address emotional wellbeing, mental health concerns, learning or executive functioning challenges, relationships, identity, or life transitions.

Our work together may include developing insight into patterns of thinking, feeling, and behaviour; building practical coping and regulation strategies; strengthening communication and problem-solving skills; and supporting growth in areas such as confidence, autonomy, and resilience. Therapy is flexible and integrative, drawing on evidence-based approaches and adapting over time as goals evolve. When helpful, collaboration with families, schools, or other professionals may be incorporated to ensure support extends beyond the therapy room.

Therapists

Our team is made up of regulated mental health providers from a range of professional, training, and practice backgrounds. This diversity allows us to bring varied perspectives, clinical expertise, and approaches to our work, while maintaining a shared commitment to ethical, evidence-based, and client-centred care.

Our clinicians include fully licensed practitioners as well as supervised trainees who are completing advanced clinical training. All services provided by trainees occur under the close supervision of experienced, regulated clinicians, ensuring high standards of care, collaboration, and ongoing professional development across our team.

Below, you can pick an available clinician to work with. You can read about our clinicians on our website: https://drjuliaryan.ca/ 

Informed Consent

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Risks and Benefits of Services

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Participating in therapy (also referred to as intervention) involves both potential benefits and potential risks. Therapy is a collaborative process, and understanding what it may involve can help you make an informed decision and feel better prepared as you begin.

Risks Associated with Therapy

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Emotional Discomfort
Therapy often involves discussing personal, sensitive, or emotionally charged experiences. This can bring up difficult feelings such as sadness, anxiety, frustration, grief, or uncertainty. At times, emotional discomfort may increase before improvement occurs, particularly when exploring longstanding patterns or challenging experiences.

Temporary Worsening of Symptoms
As awareness grows and new topics are explored, some individuals may notice a temporary increase in emotional distress or symptoms. This is a common part of the therapeutic process and is monitored carefully, with pacing adjusted to your needs.

Fatigue or Emotional Sensitivity
Therapy sessions can be emotionally demanding. Some people experience tiredness, heightened emotional sensitivity, or the need for additional rest or reflection following sessions.

Change and Uncertainty
Therapy may lead to changes in perspective, behaviour, relationships, or self-understanding. While change is often a goal of therapy, it can feel uncomfortable or unsettling at times, particularly when old coping strategies are being replaced with new ones.

Limits to Outcomes
While therapy is intended to support growth and wellbeing, specific outcomes cannot be guaranteed. Progress can vary depending on many factors, including individual circumstances, readiness for change, consistency of participation, and external supports or stressors.

Privacy and Confidentiality Considerations
Therapy services are confidential and governed by professional and legal standards. If information is shared with third parties (such as schools, other healthcare providers, or insurers), this involves disclosure of personal health information and should be considered carefully. Limits to confidentiality will be explained clearly before services begin.

Benefits Associated with Therapy

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Improved Self-Understanding
Therapy can help you develop a deeper understanding of your thoughts, emotions, behaviours, strengths, and needs, supporting greater self-awareness and self-compassion.

Skill Development and Coping Strategies
Therapy focuses on building practical skills for managing emotions, stress, relationships, learning challenges, and daily demands. These skills are tailored to your goals and circumstances.

Emotional Support and Validation
Many individuals find therapy to be a validating experience, offering a space where they feel heard, understood, and supported without judgment.

Symptom Reduction and Improved Functioning
Therapy may help reduce distress related to mental health, emotional, behavioural, or developmental challenges, and support improved functioning at home, school, work, or in relationships.

Empowerment and Confidence
Through collaboration and goal-setting, therapy can support increased confidence, autonomy, resilience, and a stronger sense of agency in navigating life’s challenges.

Collaborative Problem-Solving and Growth
Therapy provides a space to explore challenges, identify patterns, and work toward meaningful change at a pace that feels safe and manageable.

Managing Risks

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We are committed to providing ethical, high-quality care and minimizing potential risks by:

• Creating a safe, respectful, and supportive therapeutic environment
• Using evidence-based and developmentally appropriate intervention approaches
• Collaboratively setting goals and adjusting the pace of therapy as needed
• Clearly explaining the therapy process, roles, and expectations
• Maintaining professional, ethical, and regulatory standards
• Engaging in ongoing training, supervision, and professional development
• Encouraging open discussion about concerns, discomfort, or questions at any point in therapy

Informed consent is an ongoing process and we welcome questions and discussionat any stage.

Informed Consent

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Right to Withdraw Consent

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You have the right to withdraw your consent for therapy/intervention at any time, without penalty.

You will still be charged, and required to settle, fees for work completed prior to your decision to withdraw, and results may not be interpretable depending on the stage at which you withdraw.

If you are thinking of stopping services, we encourage you to speak to your clinician to create a termination plan.

Informed Consent

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Our Duty to Maintain Confidentiality and its Limits

Providers at Julia Ryan Psychology have a duty to protect your confidentiality, meaning that any information you share with your provider will not be disclosed to third parties without your informed consent except in specific circumstances as outlined below.

There are certain situations in which your provider has a legal and ethical duty to disclose information without your consent. In these instances, your provider will, whenever possible and ethically appropriate, discuss the disclosure with you beforehand, explaining the circumstances that necessitate it.

These limits to confidentiality include:

1. Imminent Harm to Others: If you disclose an intent to cause imminent, serious bodily harm to another identifiable individual, we have a duty to protect that potential victim.
2. Imminent Harm to Self: If you disclose an intent to cause imminent, serious harm to yourself, we have a duty to protect your safety. Child Abuse or Neglect: If we have reasonable grounds to suspect that a child (under the age of 18) is being, or is at risk of being, abused, neglected, or is otherwise in need of protection, we are legally obligated to report this information to the Children's Aid Society.
3. Sexual Abuse by a Healthcare Provider: If you disclose information about the sexual abuse of a client by another healthcare provider, we have a duty to report this to the provider's regulatory college or professional association.
4. Abuse/Neglect in Long-Term Care: If we become aware of abuse, neglect, or maltreatment of a resident in a long-term care facility, we are required to report this to the Director at the Ministry of Long-Term Care.
5. Other circumstances where confidentiality may be breached:
   • College Audits: As members of the CPO, our files may be subject to periodic audits to ensure compliance with professional standards.
   • Court Subpoenas: In the event of a subpoena issued by a court of law, we may be legally required to disclose certain contents of your file.

Informed Consent

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Privacy, Confidentiality, and Access to Information

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At Julia Ryan Psychology, your privacy and the confidentiality of your personal health information (PHI) are of paramount importance. This statement outlines how we manage your PHI, your rights regarding access to that information, and the limits to confidentiality we must uphold in accordance with the College of Psychologists of Ontario (CPO) guidelines and the Ontario Personal Health Information Protection Act (PHIPA).

Secure Practice Management System

We use OWL Practice, a secure, web-based system, to store and manage client records. This system is encrypted and utilizes servers exclusively located in Canada, ensuring compliance with Canadian privacy laws.

Information Stored

Client records include a comprehensive collection of your PHI, such as appointment details, billing documents, session notes, contact information, reports and test results, communications between you and your clinician, and any other client-related documents. Data Encryption, Backups and Security: All data in OWL is encrypted both in transit and at rest. Practice data is routinely backed up to protect sensitive client information and ensure compliance with PHIPA. Your data cannot be replicated or stored on servers or locations outside of Canada.

Limited Access

Access to your file is restricted to your provider(s) and other authorized members of our clinic team, all of whom are bound by strict confidentiality agreements. Any team member accessing your file is required to only access parts of the file relevant to their work. 

Data Retention

Clinical files are archived for 10 years from the date of your last service, or for 10 years after you turn 18 if you were a minor when you last received services. After this retention period, your file will be securely destroyed in accordance with PHIPA guidelines.

Privacy Policy

A detailed privacy policy is available for your review. Please contact julia@drjuliaryan.ca to request a copy.

Informed Consent

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Right to Access

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With limited exceptions, the Client has the right to access any record of their personal health information that we maintain and to request copies of that information. Information collected from others (e.g., caregivers, teachers) about the Client is considered part of the Client's Personal Health Information (PHI). As such, the right to access includes this information.

The Client is always the person who is receiving therapeutic services, including, for example, teens. If they are deemed incapable of consenting for themselves, a substitute decision maker (e.g. a caregiver) would consent to the sharing/access of information. Usually, clients above the age of 12 are considered capable to consent and obtain information.

If the Client or Client's legal guardian believes the personal health information is inaccurate or incomplete, they have the right to request corrections. We will review your request and make corrections where appropriate. There may be nominal fees associated with preparing your information in advance of its release.

Exceptions to Access

There are some exceptions to the right of access:

• Raw data from psychological services which requires professional interpretation and can only be shared with other qualified professionals.
• Information provided in confidence by a third party.
• Information that could reasonably be expected to result in serious harm to your treatment or recovery, including yourself. Any decision to withhold information on this basis will be documented in your file.
• Information that caregivers or other third parties share about themselves or others (e.g. not the Client) is also protected by confidentiality and will not be shared with the Client or another without explicit permission. In most cases, that person's information will be removed (severed) before providing access.

Youth Consent and Access

If you are the custodial caregiver or guardian of a child or adolescent who has been deemed capable of consenting to services by their clinician (i.e. a mature minor), you may not access the personal health information of that youth unless:

• The youth has provided explicit consent for you to access such information, or
• The youth has been deemed incapable of consenting to the service on their own and you are the substitute decision maker (usually a custodial caregiver with access to medical information and decision making capacity - this may be a shared duty).

Informed Consent

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Telehealth

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Telehealth includes videoconference, telephone, or even text/email forms of communication. Patients must be physically located in Ontario or Quebec during a telehealth session.

Risks and Benefits

The benefits of telehealth include increased access to services (e.g. reduced travel, more flexible schedules, etc., and, in times of public health concern, access to services in the absence of alternatives.

The risks of telehealth include potential for miscommunication with certain nonverbal information missing, limitations to some activities that are difficult to do remotely, and technology and environment related risks to privacy (e.g. someone overhearing you in your house, unsecure networks, etc.

Preliminary research has shown that interventions delivered remotely have similar efficacy to those delivered in person.

Privacy and Confidentiality

Privacy and confidentiality continue to apply to telehealth services, and as such special considerations are made to ensure these standards are upheld. Videoconference sessions take place through various platforms with enhanced and ensured security, compliant with PHIPA. Both parties involved in a telehealth session should be in a private room to protect privacy.

Technological Considerations

To maintain appropriate service, a secure, strong wifi connection and use of a laptop is necessary. If these elements are missing, there will be increased technology interruptions that will interfere with the session. If another person is present in the room, they must present themselves to the clinician before beginning. In the case of severe issues with technology during a videoconference, phone is used as back up.

Emergencies

In the case of an emergency, such as a crisis or concern for safety, your provider needs to know where you will be located during the telehealth sessions and the name of an emergency contact. Your provider will collect this information at the start of each telehealth session.

Email Correspondence

Any contacts with clients that are clinical in nature must be stored in the client's file. In addition, there are privacy concerns with regard to the use of email. Email is not secure; emails can accidentally be sent to the wrong person, they may be hacked, and they may be stored on an individual's computer or browser history. For these reasons, use of email to share confidential information (updates, clinical issues, documents) is at the client's discretion.

Secure Messaging with Owl Practice

A secure message system is available through the Owl Practice portal to encourage heightened security of personal information. To send your provider a secure message in Owl Practice, use the "messages" tab.

Informed Consent

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Use of Technological Platforms

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To enhance the quality and efficiency of our services, clinicians at Julia Ryan Psychology may use certain technological platforms. We are committed to minimizing the use of external platforms for storing PHI. Where external platforms are used, we review the privacy policies and practices to ensure those platforms are compliant with privacy regulation.

Categories of Platforms We May Use

1. Secure Communication Platforms: Google Workspace for Google Meets, communication between team members, and emails.
2. Digital Signature Platforms: For electronic signing of documents (e.g. DocuSign, Adobe Sign, etc.)
3. Note-taking support platforms: For recording of sessions that allow for transcription and support with writing notes (e.g. Klarify, Heidi)

Your Right to Choose

By signing this form, you are providing general consent for the use of external platforms by the clinic for purposes limited to those written above, though you retain the right to refuse any specific tools. Please inform us verbally or in writing if you do not consent to any data related to your service being used with external platforms so we can discuss and document the decision and implications for service.

Informed Consent

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Family Involvement and Collaboration

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We understand the importance of working with families and aim to involve family members in therapy processes when it is necessary and beneficial for the Client.

For children and youth under the age of 16, we strongly encourage both caregivers to participate to help us gain a comprehensive understanding of how the child functions in different environments and to ensure both caregivers have equal access to sharing their perspective and understanding the scope of service. If you anticipate any issues with this, it is important to inform us.

For all clients, inclusion of family members does not mean that family members have a right to the results or the information shared by others during the course of therapy.

Personal health information belongs to the Client. Therefore, the decision to share this information rests solely with the Client or their Substitute Decision Maker (e.g., a parent, guardian, or caregiver for those unable to consent).

If your provider believes that disclosing specific information (beyond the limits of confidentiality described above) to other family members would be beneficial to the Client or to therapy processes, they will discuss these benefits with the Client directly to encourage their informed consent for disclosure.

Confidentiality extends to each individual who meets with a provider at Julia Ryan Psychology. For example, a child has the right to confidentiality with their provider, including the right to decide what information (if any) is shared with their caregivers about their treatment, subject to the limits of confidentiality described above.

We prioritize the Client's autonomy and will only disclose information with their explicit permission, when ethically and legally permissible.

Informed Consent

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Ottawa-Carleton District School Board Waiver

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This section only applies to Clients currently attending Ottawa-Carleton District School Board (OCDSB) schools.

Please note that some clinicians at Julia Ryan Psychology are also employees of the Ottawa-Carleton District School Board (OCDSB).

The OCDSB requires that Clients who attend OCDSB schools, and are working with one of our clinicians who is also an OCDSB employee, understand the following points:

1. The Client or their legal custodian is aware that a similar service may be available through the OCDSB, free of charge.
2. Services sought through the OCDSB are subject to eligibility requirements.
3. Your clinician can provide information to facilitate exploring service options at the OCDSB.
4. If a clinician from our practice (who is also an OCDSB employee) is asked by an OCDSB school to provide consultation or supervision for a Client they have seen in private practice, they must declare a conflict of interest. In this scenario, the clinician will request that a different OCDSB psychology staff member handle the required school-based consultation or supervision.

Informed Consent

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Contact Us

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You can contact the clinic at 613-699-0825 or email admin@drjuliaryan.ca if you have questions about the information in this form while completing it.

End of Section: Informed Consent

Fees and Payments

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Fee Structure

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The fees at Julia Ryan Psychology vary by clinician and service.

For Intervention Services

Fees vary depending on a clinician's training background and experience, ranging from $130 to $250 per hour with the lower end representing student trainees and the higher end experienced Ph.D. level psychologists providing specialty care. 

A clinical hour is typically 50 minutes of direct contact. 

Billable Fees

All service fees apply to direct client contact, as well as non-contact clinicial work such as preparing documentation, consulting with other professionals, completing forms, etc.

Payment

Fees can be paid either by e-transfer to info@drjuliaryan.ca or by credit card. If by e-transfer, the payment is due immediately upon receipt of the invoice.

We require a credit card on file for all clients.

Late Fees

A late penalty of $5 per day will apply for late payments which will be applied at the next invoice. Subsequent sessions will not be scheduled until previous balances are paid.

Cancellations and Missed Appointments

If the client cancels the appointment without 48 hours of advanced notice or does not show up, we will apply a late fee of 50% of the session fee.

Exceptions may be made for illness, self-isolation, or other extenuating circumstances at the discretion of the clinic and provider.

Privacy and Access to Information

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Privacy legislation regulates who can access a Client's information and under what circumstances. If someone other than the Client or guardian is paying for service, they are permitted to communicate with the clinic regarding billing matters, invoices, and insurance claims. However, they are not entitled to accessing the Client's health information including details about scheduled appointments, treatment plans, or clinical findings.

Fees & Payment

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Insurance

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Mental health services are not covered by the Ontario Health Insurance Plan (OHIP). Many extended health benefit plans cover psychological services. It is your responsibility to check your coverage before initiating services. 

Depending on your insurance policy or work arrangement, health insurance and employee assistance programs (EAPs) may not cover the entire cost of our mental health and psychological services.

We can perform direct billing with some insurance companies, including:

• Canada Life
• Coughlin
• Desjardins
• Equitable
• First Canadian Insurance
• IA Financial
• Johnson
• The Public Service Health Care Plan (PSHCP)
• And others

If you or your child are covered under any of the eligible plans above, or would like to check if we can do direct billing to your plan, please complete an authorization form for each plan providing coverage. If you are a parent or caregiver who would like some of the hours to be billed under your name, please also complete the form for yourself.

If you request for direct billing below, you will automatically be sent the direct billing form upon submission of this form. If you'd like a copy of the form now, it can be found here:

TELUS Health eClaims Consent Form

Please email the form to admin@drjuliaryan.ca. When a patient has two insurance plans, the primary coverage is determined by the 'Birthday Rule': the plan belonging to the person whose birthday (month and day) falls earliest in the calendar year holds the primary insurance policy.

Note that many Equitable and Manulife insurance plans only payout to the client and not the provider. This means that we will collect fees from you by credit card or e-transfer, and can submit insurance claims to Manulife on your behalf. Manulife will then reimburse you.

Fees & Payment

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Credit Cards

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We require all clients to have a valid credit card on file.

We ask all clients to add a valid credit card to their file in case of unpaid or uncovered fees. Your credit card number will be stored securely on file and the payment will be processed through Stripe; we do not have an on-site machine.

After completing this form, we will reach out to you with next steps for your therpy file including instructions for adding a credit card to the file.

Acknowledgement of Fees & Payments

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Intake Questionnaire

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We would like to collect some basic information about the reason for seeking services and relevant mental health background.

For open-ended questions, please consider being brief. For those that have more to tell us, please consider keeping more detailed notes separately to share with us after the initial file review.

Intake Questionnaire

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Answer the following questions to the best of your ability.

For open-ended questions, please limit your answer to a few sentences.

Intake Questionnaire

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Intake Questionnaire

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Intake Questionnaire

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Intake Questionnaire

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Intake Questionnaire

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