This information is requested for our records and will be held in confidence and not shared with anyone,
unless you release authorisation for us to do so. If the assessment is for a child, please enter their name and date of birth on the form and not yours.
Your informed consent is required prior to services being provided by Sandra Ward, MEd SACP under the supervision of Dr. Andrew Moss, licensed Clinical Psychologist. As the licensed professional, Dr. Moss will have access to all information provided for the purposes of the assessment. If you have any questions about any of these matters, please ask either Sandra Ward or Dr. Andrew Moss before signing.
CONSENT FOR ASSESSMENT AND/OR TREATMENT:
I understand that I am consenting to undergo one or more of the services provided in this practice, for example; psychological assessment, psychological counselling or psychological consultation.
I understand that the psychological assessment may take the form of clinical interviews, observations, and administration of a variety of psychological tests and measures. As part of the assessment process, information may be collected from the parent/guardian and/or school personnel in the form of interviews and/or checklists or rating scales. The information obtained from the assessment will be used to understand and describe how the client learns, processes information and functions emotionally and behaviourally and may include a formal diagnosis, provided by Dr. Andrew Moss.
I have been informed of the nature of this assessment and I understand that Sandra Ward and Dr. Andrew Moss will subsequently review the results of this assessment with me and explain any forthcoming recommendations. The final documentation of the assessment will be a full assessment report of which I will receive an original copy.
CONSENT FOR THE COST OF THE SERVICE PROVIDED:
I understand that I am expected to pay a retainer of $1,000 before the first appointment, which will be held in a
non-interest-bearing trust account and will be applied to the final invoice. The outstanding balance is payable in full before the assessment feedback session. I have been provided with the maximum quote prior to the initiation of this assessment, which I have agreed to pay. I understand that I will not be personally responsible for payment of the fee if I have been referred directly by a government agency, my insurer, or though the Ontario Legal Aid Plan.
I understand that clients are seen by appointment only and that any appointment cancellation made less than one business day or 24 hours in advance of the scheduled time will be charged to me at the full hourly rate of $225.00. (Please note that most insurance companies do not reimburse for missed appointment charges so this will be payable by you.)
LIMITS TO CONFIDENTIALITY:
I understand that information shared with Sandra Ward and Dr. Andrew Moss is completely confidential with the following exceptions: If any person being treated threatens violence or harm to him/herself or to another person, any suspicions of child or dependent adult abuse, any incident of a regulated health professional who has sexually abused a client, or a court order to release information from a record. In these instances, Dr. Moss has a duty to report the information to the relevant authorities. Dr. Andrew Moss regularly consults with other therapists during which they discuss specific aspects of his clinical work in order to ensure the quality of service provided. Nevertheless, the consulting professional is bound by the same confidentiality as Dr. Andrew Moss and no identifying information pertaining to specific clients will be divulged outside of Dr. Moss’s professional relationship.
No information about your treatment or appointments will be released without your prior, written permission except as outlined above or as required by law. When consenting to the disclosure of personal health information, you may restrict Moss Psychology from sharing all or any part of your personal information.
If Dr. Andrew Moss perceives that this information is reasonably necessary in order for another health service provider to provide appropriate service, he is required by law to inform the other provider that you have refused consent to provide some needed information.
CONSENT FOR THE COLLECTION OF PERSONAL INFORMATION:
I understand that to provide me with psychological services, Moss Psychology will collect some personal information about me (e.g., address, telephone number, email address etc).
I understand how the above information practices apply to me. I have been given the opportunity to ask any questions I have about these information practices, and they have been answered to my satisfaction.
I hereby consent to the provision of psychological assessment to either myself or the child for whom I have legal custody and/or parental rights to authorize an assessment. If any custody order pertaining to this client has been granted by the court, I have the authority to provide this consent and I have informed Moss Psychology if any other party's consent is required under the order.
This consent will be in effect for a year from the date of my acceptance on this document unless I should exercise my right to rescind, which I have the option to refuse or withdraw at any time.