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Consent for Psychological Treatment Services
I acknowledge that I have requested a Psychological Consultation for myself/my child from Dr. Season Tompkins.
I understand that Dr. Tompkins is registered with the College of Psychologists of Ontario. I understand that the initial consultation appointment will gather information about me/my child to help determine if Psychological services may be appropriate. At the end of the initial consultation, Dr. Tompkins will discuss recommendations with me. As part of the consultation process, I may be asked to complete questionnaires. These will provide Dr. Tompkins with more detailed information about my/my child’s functioning which will help inform the treatment process. 
If psychological treatment is recommended, I understand that I can choose to pursue treatment for myself/my child. The potential risks and benefits of psychological treatment have been explained to me. I understand that I can withdraw my consent for treatment at any time. While therapy can provide long lasting benefits from symptoms, it is an emotional investment, can be hard work, and it can sometimes take time before there is symptom relief.  
Limits to Confidentiality
I understand that the information shared with Dr. Tompkins is kept confidential and is not shared with third parties without written consent. This also applies to children working with Dr. Tompkins, and generally she will not share specific information that a child tells her with the child’s parents without the child’s knowledge and permission. Dr. Tompkins will share general observations about progress being made and encourages children to share their goals with parents as well as any information that may help their parents support them in achieving those goals. 
The following are situations where legal and ethical considerations prevent confidentiality from being maintained and information may be released with or without my consent:
  1. If there is a clear reason to believe you/your child are/is at risk of hurting yourself/themselves or someone else, then a psychologist must take action to protect you/your child or a third party even if this means breaking confidentiality.
  2. In cases of suspected child abuse of a child under the age of 16, including physical, sexual, or emotional abuse, or cases of neglect, psychologists must immediately report their concerns to Family and Children’s Services.
  3. If it is discovered that a regulated health care professional (e.g., physician, massage therapist) has sexually abused, assaulted or harassed a patient, a psychologist must report that practitioner to their regulatory body. We are not required to identify the patient unless we have received permission to do so, or there is an order to release the patient’s name by the practitioner’s College.
  4. The contents of your file may be released if subpoenaed by a court of law or as required by the Missing Persons Act.
  5. Our records and files may be reviewed by the College of Psychologists for quality assurance purposes and complaint investigations.
  6. In cases of suspected abuse of or neglect of a resident of a retirement home or long-term care facility, this information will be disclosed to the appropriate authority (i.e., Registrar of the Retirement Homes Regulatory Authority or the Director within the Ministry of Health and Long-Term Care). The harm/risk of harm may result from: improper or incompetent treatment or care; abuse by anyone; neglect by staff; unlawful conduct; misuse or misappropriation of a resident's money.
I acknowledge that I am aware of the fees for psychological services, which may include the initial consultation, treatment sessions, or agreed upon services provided outside of session (e.g., preparing reports or letters, phone consultations). I understand that payment is due at the end of each session and it is my responsibility to determine what insurance coverage I have and to submit the receipts to the insurance company for reimbursement.
Occasionally, third party insurance providers contact Dr. Tompkins to verify that claims submitted match the services provided. In these instances, the insurance company will ask for the name and date of services provided, but will not require any information about what was discussed in session or the reasons for the session.
I give permission for Dr. Tompkins to communicate with my insurance company for the purposes of validating my claims. I understand that the only information provided to the insurance company will be client’s name(s) and dates of service.
Email Communication
If you communicate with Dr. Tompkins by email, please be aware that email is not a completely confidential form of communication, and as such, you are encouraged to limit the amount of personal health information that you email.  If you choose to email Dr. Tompkins personal information, you are accepting the risk that your information may not be confidential. We do use email to send appointment reminders, which contain little personal health information.
Similar to phone calls, email communication is responded to during business hours.  As such, email communication should not be used for urgent matters. I understand that Dr. Tompkins does not offer after hours or emergency treatment. For after hours acute care, I will contact the Waterloo Crisis Services (Here 24/7) at 1.844.437.3247 or, in an emergency or in cases of imminent danger, I will call 911. I will update Dr. Tompkins on any such events as soon as possible.
Cancellation Policy
I understand that 48-hours notice is required to cancel or reschedule an appointment. If I do not give sufficient notice or I fail to show up to an appointment, I will be charged a missed appointment fee of $40.00. The fees for missed appointments are usually not covered by third party insurance providers.
I acknowledge that I have been given an opportunity to ask questions related to this consent. I understand and consent to all of the above conditions and I hereby consent to participate in this consultation and/or treatment process.
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