905-641-4451
289-213-0919
Informed Consent
Informed Consent: You are consenting to therapy for yourself, or a dependent, consisting of Cognitive Behavioural Therapy services, including online or on phone therapy. Services are provided by John Henderson miGCBT, a CBT & CBT-I Practitioner who is certified by Achology UK. (Certification No. UC-d8e69f63-3ad1-4f3b-9549-619f4cf73def) and by iGCBT. You understand that as your therapist, Niagara CBT Clinic have the sole discretion to suspend or terminate therapy, pursuant to the ethical guidelines governing CBT care. CBT has both benefits and risks. Risks may include experiencing uncomfortable feelings because the process of CBT often requires discussion in the challenging aspects of your life. However, therapy has been shown to have benefits for individuals who undertake it. CBT often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But there are no guarantees about what will happen. To be most successful, you will often have to work on things we discuss, outside of sessions.
Telephone and Electronic Services: To ensure private, confidential, and compliant communication, clients are encouraged to contact me via telephone or through Chat on the clinic’s website. However, if you need to contact me via a non-secured email or text, please be aware that this is not a secure way of contact and recommend limiting correspondence to administrative issues such as appointments or billing. Electronic services may be updated to ensure more security for clients. Online (video) has both benefits and risks and is provided through Zoom, Chat or other online media platforms. Risks may include technical difficulties while benefits can include convenience and flexibility. Your signature below acknowledges that if you agree to online therapy, you understand there are risks and benefits and limits of security if using a non-PHIPA compliant mode of communication.
Payment for Services: You understand that as a client of Niagara CBT Clinic, you are responsible for the payment of fees charged for our services. Methods of payment accepted are, cash, cheque, credit card, debit or etransfer and become payable at the conclusion of each session. You also understand that Niagara CBT Clinic does not bill insurance companies directly and that you are responsible for full payment of services provided by us even if your insurance company refuses to pay you. You also understand that failure to pay for services rendered may result in legal action. Fees for services will be billed at the Session Rates which can be obtained by calling the clinic on 905 641-4451. Receipts for all payments are available on request.
Appointments and Cancellation Policy: Appointments for Assessments will ordinarily be 60 minutes and CBT Sessions will be 45 minutes in duration at a time and frequency agreed on prior to the appointment. Since appointment scheduling involves the reservation of time specifically for you, a minimum of 48-hour notice is required for rescheduling or canceling an appointment. You understand that you will be charged $50 for a session that is missed or canceled with less than 48-hour notice. If you miss more than two appointments without calling to reschedule or cancel 48 hours in advance, or if you have excessive cancellations, you understand that you may be suspended or terminated as a client. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time due to other clients appointments.
Confidentiality: Niagara CBT Clinic’s policies about confidentiality, as well as other information about your privacy rights, are fully described in separate documents entitled Our Privacy Policy at www.niagaracbtclinic.com/our-privacy-policy You have been provided with a copy of those documents and we will discuss those issues. Please remember that you may reopen the conversation at any time during our work together.
Professional Records: Niagara CBT Clinic keeps appropriate records of the therapy services that it provides. Your records are maintained securely online and on file and provides a very high level of security protecting electronic information. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. If Niagara CBT Clinic refuses your request for access to your records, you have a right to have their decision reviewed by another mental health professional, which they will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.
Emergency Procedures: While as your therapist, Niagara CBT Clinic frequently accesses email, texts, and voicemail, you understand that you should not solely rely on reaching us for emergency situations. If you have a medical emergency, you are aware that you should contact your local hospital, police department, or dial 911.
Social Media: Due to the importance of your confidentiality and the importance of minimizing dual relationship, Niagara CBT Clinic will not accept invitations via social networking sites.
Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by the laws of the province of Ontario, and not by a lawsuit or resort to court process except as Ontario law provides for judicial review of arbitration proceedings. Both parties to this contract by entering it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
I have read, understand, and accept the foregoing policies and by my signature on Niagara CBT Clinic's Informed Consent Form acknowledge both agreement and receipt.