Your informed consent is required prior to services being provided by Moss Psychology, hereafter referred to as your “Practitioner”. All services are either directly provided by, or supervised by a licensed Psychologist who retains responsibility for all work conducted. If you have any questions about any of these matters, please ask your practitioner or supervising Psychologist before signing this consent form.
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; assessment, therapy or consultation..
CONSENT FOR THE COST OF THE SERVICE PROVIDED:
I understand that I am expected to provide payment immediately following each session, or at the feedback session of a psychological assessment. I have been informed of the cost per session of input. In the case of a psychological assessment, I have been provided with the maximum quote prior to the initiation of the assessment, with which I have agreed to pay. This does not apply to Blue Cross/Veterans Affairs clients who have been pre-approved for services.
I understand that clients are seen by appointment only and that I may be personally charged The Full Cost of any missed appointment, late arrival (beyond 20 minutes of the scheduled appointment time), or cancellation made less than one business day or 24 hours in advance of the scheduled time. (Please note that YOU are personally responsible for ALL missed appointment charges and most funding agencies will not reimburse this fee.).
Repeated cancellations, late arrivals or missed appointments may result in the termination of services. My Practitioner reserves the right to change an in-person appointment to a remote appointment (either via telephone or video conferencing online platform), should they deem it to be necessary for either practical reasons or in the interests of mine or other’s physical safety (i.e., during a pandemic).
LIMITS TO CONFIDENTIALITY:
I understand that information shared with my practitioner is completely confidential with the following exceptions: If any person being treated threatens violence or harm to themselves or to another person, any suspicions of child or dependent adult abuse, if there are reasonable grounds to suspect, that another registered health care professional (e.g., a physician, dentist, chiropractor) has sexually abused a patient, or a court order to release information from a record. Your practitioner regularly consults with other regulated practitioners during which time they may discuss specific aspects of your input, in order to ensure the quality of treatment provided. Nevertheless, the consulting practitioner is bound by the same confidentiality as your own practitioner.
Information of any kind about your treatment or appointments will not 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 your practitioner from sharing all or any part of your personal information. However, if your practitioner perceives that this information is reasonably necessary for another health service provider to provide appropriate service, they are 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 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 that I have about these information practices, and they have been answered to my satisfaction.
