Description of Services

1. Participation carries some risks, including but not limited to changes in mood and behavior, which may also have an impact on my relationships and/or on my work and daily tasks.

2. What I say during counselling sessions will be held in strict confidence and will not be divulged to anyone without my express written consent, with the exceptions listed below:

• Confidential material may have to be divulged if subpoenaed by the courts, requested by WCB, or if I am deemed to be at risk of harm to myself or others, or if there is an imminent or ongoing risk of child or elder abuse.
• The NS Board of Examiners in Psychology (NSBEP) has the right to audit a psychologist’s files if they perceive a need to protect the public.
• Some aspects of confidentiality may have to be breached if it is deemed necessary to secure payment for delinquent accounts, through a collection’s agent or the courts.
• My psychologist will seek my express written authorization to communicate with third parties, including my other health care professionals (i.e. family doctor). These health professionals may be entitled by law to share this information with other health professionals, not expressly authorized by me. In these cases, my psychologist has no control over such sharing of information and cannot be held responsible for same.
• To maintain a level of professional integrity, psychologists are required to consult with other psychologists on an ongoing basis. Every effort is made to ensure client confidentiality.
• For psychologists on the candidate register, digital audio recordings of counselling sessions may be made. These recordings may only be shared with the psychologist’s NSBEP supervisor and are made with the express purpose of ensuring and maintaining best practices in client care.
• If I request information regarding my treatment be released to a third party (e.g. family doctor, lawyer, or insurance provider), and I sign a consent to release form, this information will be provided to those parties authorized. My treatment provider will review with me what information will be shared prior to its release. If I am receive couples or family counselling, everyone involved must consent for the information to be released.
• If I lodge a legal or ethical complaint about my psychologist, they are entitled to use confidential information to build a case against the complaint to explain their actions.
• If I disclose an ethical violation committed by another mental health or health case professional, my psychologist may be required notify the appropriate authorities (e.g. their governing board).

3. Client files may be accessed by Marsh-Knickle staff members for internal purposes such as administration, practice management, and IT support only. These staff members have signed confidentiality agreements and will not access this information unless it is necessary to carry out their functions.
My treatment provider maintains a record of my personal information and their contact with me, as required by their professional standards of practice. These records may be digitally stored in the practice management software which meets the standards of the Personal Health Information Act (PHIA) and psychological standards of practice.
These records include, but are not limited to, my full name, address, phone number, email address, date of birth, emergency contact information, records of contact, and chart notes summarizing pertinent information from each appointment with my provider.

As the therapeutic relationship is an essential part of the session’s effectiveness, we recommend that clients evaluate whether they feel this clinician is the best fit for them. Please don’t hesitate to let us know if you would like to be referred to someone else.

SPECIAL CONSIDERATION FOR ADOLESCENTS:

There is no set age limit for an individual to be considered competent to give consent, mature minor status is typically considered during adolescence and on a case-by-case basis.

FEES:
We accept Credit, Debit, E-Transfer, and cash.
The therapy hour allows for 50 minutes with the Psychologist and 10 minutes reserved for file review and notations. Fees for this service, as well as for consultations, reports, and letter writing, are as follows:

$225 per hour for individual sessions
$240 per hour for couples and families

Payment for therapy is due prior to the session. Receipts for services of Registered Psychologists and Psychologists on the Candidate Register are income tax deductible as health-care expenses. Please Note: If the outstanding payment is not paid within 30 days, we have the right to forward to a collection’s agent.

MISSED APPOINTMENTS, INSUFFICIENT CANCELLATION OR RESCHEDULING NOTICE:

As a courtesy to clients on our waiting list and to your Psychologist, our policy concerning appointments missed or rescheduled without sufficient notice is adhered to without exception. In signing this consent form, you are agreeing to the terms outlined below. If you require clarification of any point, please discuss it with your Psychologist before signing. A booked appointment is time that has been reserved for your exclusive use. This time remains your financial responsibility unless you release it for use by someone else by providing at least 24-hours’ notice of cancellation/rescheduling. Monday appointments must be cancelled/rescheduled by Friday at 12noon. Appointments scheduled on the first day following a holiday must be cancelled/rescheduled by 12noon on the last business day before the holiday. Voicemail or email messages left after business hours or on weekends or holidays do NOT count as sufficient notice and will remain your financial responsibility. 48 hours’ notice is required for extended appointments (appointments scheduled for 2 hours or longer).The cost for time missed or cancelled/rescheduled without sufficient notice rests with you. In the case of illness or inclement weather, a telephone session can be arranged for you. Fees for missed appointments must be paid in full to retain any further appointments in our schedule. The fee for missed appointments is the same as for appointments attended. Appointments must be cancelled/rescheduled by phone/e-mail during business hours. Receipts for missed appointments will indicate “Missed Appointment” and may not be covered by insurers. To note them as otherwise could defraud third party payers.

LATE ARRIVALS AND EARLY DEPARTURES: Unfortunately, time lost through late arrivals or early departures cannot be made up. Please call our office if you are going to be late, and your Psychologist will wait for you to begin your session.

Your Rights under the Personal Health Information Act (PHIA)

1. You have the right to access and request a copy of your personal health information from the DHW. There are limited exceptions to your right of access. For example, you may not be given access to information that was collected during an investigation or that includes personal health information about another individual.

2. You have the right to request a record of who accessed your personal health information on our electronic information systems.

3. You have the right to request that we correct your personal health information if you feel it is not accurate, complete, or up to date. Some exceptions apply. For example, we cannot change the professional opinion of a health practitioner.

4. You have the right to request a limitation on the way we collect, use, or disclose your personal health information. The Department of Health and Wellness (DHW) has the responsibility to take reasonable steps to comply with your request. When you make such a request, we will discuss with you the risks associated with such a limitation, which we call "masking." If you ask us to mask your personal health information, we have the obligation to notify any custodian that the information is incomplete if a disclosure if necessary.

5. You have the right to make a complaint to the DHW concerning how your information was collected, used, maintained, disclosed, or disposed of by the department in accordance to our obligations under PHIA.

Payment Authorization:

I agree that fees will be charged to my Credit Card for appointments attended, missed, or cancelled without sufficient notice, as described above, and I hereby authorize any such charges. This authorization guarantees that my future appointments will be reserved for me.*

*** I understand that fees for appointments missed or cancelled without sufficient notice, as described above, will be paid immediately. I realize that without immediate payment, appointments already scheduled for me will be cancelled and that my account will be forwarded to a collections agent if it remains unpaid after 30 days. ***

I have read, understood, and agree to the terms noted above: