Intake and Waiver

Please fill out the following form prior to starting services

Parent Name

Child/Youth Name

Date of Birth - Child/Youth

Phone

Child/Youth School and Grade:

Why are you seeking therapy?

Cancelation Policy: If you need to cancel or reschedule an appointment (including workshop and group sessions), you must cancel 24 hours in advance. All appointments cancelled or missed with less than 24 hours notice will be paid in full. I acknowledge the cancelation fee.

Yes

Illness Policy: For home visits, I will cancel if any member of my family has Covid, Flu or RSV. For school visits, I will follow the policy of the school, and advice the therapist of any illness in my home.

Yes

Privacy and Confidentiality Policy: No information will be released to a third party without your prior written authorization. You have the right to withhold or withdraw consent to, or place conditions on, the disclosure of your information at any time. Exceptions to confidentiality include obligations for your therapist to: • Inform a potential victim of a client’s intention to harm them; • Inform an appropriate family member, health care professional, or police if necessary of a client’s intention to end his or her life; • Release a client’s file (or portions thereof) if there is an investigation or court order to do so; • Inform the Children’s Aid Society if there is suspicion of a child at risk of harm or in need of protection due to neglect, or physical, sexual or emotional abuse; • Report sexual abuse of a client by another regulated health professional; • Report elder abuse of a resident in long-term care. By clicking the box, I agree to the above.

I accept terms & conditions

I declare that the info I’ve provided is accurate & complete

Initials

Thanks for submitting!