Informed Consent:
​You are consenting to treatment for yourself, or your dependent, consisting of CBT services, including online or on-phone therapy by Niagara CBT Clinic. You understand that as your therapist, Niagara CBT Clinic have the sole discretion to suspend or terminate therapy, under 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 is beneficial for individuals who undertake it. CBT significantly reduces feelings of distress, increases satisfaction in interpersonal relationships, greater personal awareness and insight, and increases 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.
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Telephone and Electronic Services:
To ensure private, confidential, and compliant communication, clients are encouraged to contact me via telephone or 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 is recommended to limit correspondence to administrative issues such as appointments or billing. Electronic services may be updated to ensure more security for clients. Online (video) has benefits and risks and is provided through Zoom or Chat. 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 benefits, and security limits if using a non-PHIPA-compliant mode of communication.
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Payment for Services:
You understand that the fee agreement is a legally binding contract and that you are under obligation to pay for services provided to Niagara CBT Clinic at the time of the session or prior to, and that the fee agreement is valid while receiving services and may be renegotiated pursuant to business costs. You also understand that Niagara CBT Clinic does not bill insurance companies directly and that you are responsible for full payment of services. You also understand that failure to pay for services rendered within the negotiated time frame may result in legal action. Agreed fee for services will be billed at the Session Rates as posted on this website.
Insurance Billing: We do not bill insurance companies directly.
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Appointments and Cancellation Policy:
Appointments for Assessments will ordinarily be 60 minutes and CBT Sessions will be 50 minutes in duration, at a time and frequency we agree on before 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 hours ' notice, even in cases of emergency. If you miss more than three 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.
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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/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.
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Professional Records:
I am required to keep appropriate records of the therapy services that Niagara CBT Clinic provides. Your records are maintained securely online and on file and provide 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 your 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 healthcare provider at your written request.
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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 relationships, I will not personally accept invitations via social networking sites.
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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.