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Psychotherapy Service

Intake and Consent Form

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Consent to Psychotherapy Service

Nature of Psychotherapy Services

Psychotherapy involves a collaborative process between client and therapist to explore emotional, cognitive, behavioural, and relational concerns. It may include verbal dialogue, creative expression (if appropriate), reflection, and goal setting. As a Registered Psychotherapist (RP) in Ontario, I am governed by the College of Registered Psychotherapists of Ontario (CRPO) and bound by its ethical standards.


Confidentiality & Its Limits

All information you share during sessions is confidential and will not be disclosed without your written consent, except in the following situations:

  • There is a risk of serious harm to yourself or others

  • Suspected abuse or neglect of a child or vulnerable person

  • If records are subpoenaed by a court of law

  • As otherwise required by law or CRPO regulations

In couples/family sessions, confidentiality applies to the group, not to individual disclosures.


Virtual Sessions

I use Zoom as the platform to conduct our virtual psychotherapy session. A secure, password-protected meeting link will be provided for each session. Zoom offers built-in privacy settings to safeguard your confidentiality; however, as with any online platform, absolute privacy cannot be guaranteed. You are responsible for securing your own environment (e.g., using headphones, private space). Sessions will not be recorded unless discussed and agreed upon in writing.


Scheduling, Cancellations & Fees

Sessions are approximately 50 minutes or 30 minutes in length unless otherwise arranged. Payment is due after each session unless other arrangements are made. You may cancel or reschedule with at least 6 hours’ notice.Cancellations made with less than 6 hours’ notice may be subject to a $50 late cancellation fee. No-shows will be charged the full session fee.


Payment & Receipts

You will receive a receipt after payment, which you may use for insurance reimbursement if your provider covers services by Registered Psychotherapists. I do not offer direct billing. It is your responsibility to confirm your coverage.


Interprovincial & International Services

I am licensed to practice psychotherapy in Ontario, Canada. While I am allowed to practice psychotherapy with clients reside outside Ontario, you are responsible for checking with your insurer and local laws to determine whether psychotherapy is regulated in your area and if it is eligibility for reimbursement or participation. Sessions provided to clients outside Ontario may not be eligible for insurance reimbursement. If you need help looking for information regarding this area, please kindly contact me.


Risks and Benefits

Psychotherapy can bring about improved insight, emotional relief, and positive life changes. However, it can also involve discomfort such as difficult emotions, challenging realizations, or temporary worsening of symptoms. There is no guaranteed outcome.


Client Responsibilities

You agree to participate willingly and respectfully in the therapeutic process. You understand that progress may vary and that your active engagement between sessions is often helpful.


Consent & Agreement

Please read and acknowledge the following:

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“Pour out your heart — God is your refuge.” — Psalm 62:8
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