WPATH Assessment Consent Form

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AUTHORIZATION FOR PSYCHOLOGICAL SERVICES

THE PURPOSE AND NATURE OF A WPATH ASSESSMENT

A WPATH Assessment entails the gathering of personal information including but not limited to information about your lived experience of your gender identity, gender dysphoria, relevant medical and mental health information, and reasons for seeking gender-affirming care.

The purpose of a WPATH Assessment is to assess your needs and suitability for gender-affirming care which often requires one appointment but may in some cases require additional appointments to allow the service provider to obtain the necessary information.

Participating in the WPATH Assessment is on a voluntary basis, which means you can withdraw your participation in the assessment at any time.

There are minimal risks associated with completing this assessment. However, we risks can include emotional distress as a result of discussing your mental health history, gender identity, and the specifics of gender-affirming care. Should this occur, you are welcome and encouraged to seek psychological services with a treatment provider to address your concerns and receive the necessary support.

There are no known benefits from participating in this assessment. However, some people may find it beneficial to share their journey with others and discuss their gender identity as it may provide validation and affirmation of one's lived experience.

CONFIDENTIALITY

To maintain a level of professional integrity, Psychologists are required to consult with other Psychologists on an ongoing basis. At Marsh-Knickle & Associates, all independent practitioners meet regularly to discuss individual cases to maintain a best care practice. We understand that information you share in therapy or during an assessment is of a personal nature, and that you would want it to remain private. Confidentiality will be maintained unless you give us specific, written permission to share information with another person or agency. However, we are required by law to disclose confidential information if there is reason to believe that a child or elderly person is being, or is at risk of being, abused or neglected, or that you may be in danger of harming yourself or others. However, if you have been sent for an assessment and/or counselling by a third party (for example, the courts, Workers Compensation), we may be required to release information to that third party. On rare occasions, the courts may order us to release therapy records or psychological assessment reports. Also, under rare circumstances the NSBEP has the right to audit a psychologist’s files if they perceive a need to protect the public.

LEGAL

If your case involves a legal matter you will be referred outside of Marsh-Knickle Psychological Services Inc.

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 FOR SERVICES

The total cost for a WPATH assessment is $337.50. This includes a 1-hour appointment for the assessment, and 30 minutes for your psychologist to write a report covering the findings. A 15-30 minute follow-up appointment to go over the report is also included in the cost. You, the client, are responsible to make payment to your psychologist at the end of the assessment session.

Credit, Debit, e-Transfer, or cash are accepted. A receipt will be issued to you. Our fees qualify as medical expenses for income tax purposes. Some extended health care insurance plans may reimburse you for part of all of our fees. It is your responsibility to determine what your coverage is.

CANCELLATION OF APPOINTMENTS

As a courtesy to your psychologist, please notify us 24 hours before your appointment if you cannot keep it. (Please call by noon on Friday to cancel Monday appointments). Except in emergencies, we will bill you at the rate shown below for sessions missed without 24 hours’ notice.

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.*

PLEASE NOTE: All outstanding fees exceeding 30 days from scheduled service date will be forwarded to a collection agency. Also, note that all returned NSF cheques will be billed an additional $25.00

PROBLEMS DURING THE ASSESSMENT

You have the right to rescind consent at any time, and you have the right to be treated with respect and dignity in a safe environment. If you have any concerns about the services you receive, or if you feel at any time that the services you are receiving are not helpful, please talk with your psychologist about your concerns. Referrals to other psychologists can be provided.

OTHER AREAS OF DISCUSSION

We encourage you to ask questions at any time about any aspect of our services; for example:

What is the background of your psychologist, and what does he/she feel most qualified to examine or treat?

By typing your name below, you agree that you have read and understand the above information.

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