WELCOME TO MY OFFICE

 

Agreement to Enter Therapy

 

Before you make a decision about entering therapy with me, there are several things that you should be aware of.  The following pages describe my office policies (including standards of practice, fees, payment, cancelling appointments, treatment of questionnaires, reports to other insurance companies or others, contents of a client file), as well as issues relating to confidentiality.  Please read through all of the information and feel free to ask questions before making your decision.

 

OFFICE POLICIES

 

Standards of Practice

 

As a Psychologist, I maintain standards of professional practice and ethical conduct in accordance with the college of Psychologists of Ontario.

 

Fees and Payment

 

My fees are in keeping with those established by the Ontario Psychological Association.

 

My services are not covered by OHIP, but they are covered (at least in part) by many extended health care plans (e.g., Public Service Health Care Plan, Blue Cross, Workers’ Compensation Board, etc.).  Each plan has its own rules and regulations.  Some cover 100% of the fee, others as little as $20 per session.  Most have a total amount per calendar year that may be reimbursed for each person in the family.  For couples doing couple therapy, the two individuals’ coverage is added together for twice the total of the individual coverage.

 

You are expected to pay me for the entire cost of the session and apply to your insurance company for reimbursement for the covered part of the session. 

 

Many policies require a physician’s referral in order for you to receive reimbursement.  Prior to your first session, you should check what coverage you have and what restrictions/requirements your policy places on psychological services.

 

Payment is due at the time of service.  Invoicing and payment will take place at the beginning of each session (to avoid running into the next client’s appointment time).  An invoice for each session will be provided to you.  I accept cheques, cash, and VISA payments.  You may write a cheque post-dated up to one month following your appointment.

 

Late Payments

 

A service charge of 1.5% per month will be charge on all accounts that are more than 30 days overdue.  A fee of $20 will be charged for each cheque that is returned because of insufficient funds in your account.

 

Allowable Income Tax Deduction

 

Psychological services are considered a medical expense for income tax purposes.  Any part of the fee that is not covered by your insurance is tax deductible.  Please retain a copy of your invoice for income tax purposes.  There will be a $20 fee if I am asked to provide a year-end summary of your invoices.

 

Cancelling Appointments

 

If it is necessary for you to cancel an appointment, please do so a full 24 hours prior to your scheduled session.  Appointments that are missed, or are canceled with less than 24 hours notice will be charged at the regular fee for the hour that was set aside for you.  A message left on my voice mail is adequate for cancelling your appointment, even during evenings and weekends.  Please do not use e-mail or fax to cancel appointments, because I may not be able to access them promptly.

 

Length of Sessions

 

Although a full hour is set aside for each client, the actual session is traditionally considered to last 50 minutes.  This allows the therapist to use the remaining 10 minutes to complete session notes.  Because I tend to allow a full 60 minutes per session, I must ask my clients to leave the office promptly to allow the next client to begin his or her session on time.

 

Assessment Procedures and Reports

 

Some clients are referred for issues that require testing and/or reports for insurance companies or the court.  If relevant, I will discuss the costs of these services with you at the time of service.  Clients will be expected to pay for questionnaires that are lost or returned in an unusable condition.

 

If your insurance company requires frequent treatment updates, a fee may be applied.  I do not charge to complete simple forms, but I do charge for writing letters and reports.  You will be expected to pay this fee and then discuss reimbursement with the insurance company.

 

 

Contents of a Client File

 

All information relating to your care is kept in my file.  You have the right to see anything in my file that I have originated.  I am not permitted to show you documents that are sent to me by other health care providers. 

 

In keeping with the regulations of the College of Psychologists of Ontario, once information goes into my file, it must remain there.  The types of documents that are contained in my file include:

 

 

1.      session notes that I take during our appointments

 

2.      notes that I make during telephone calls with you

 

3.      notes that I make during conversations or telephone calls with any person that you have authorized me to discuss your case with

 

4.      my copy of each Form 14 that you sign giving me written permission to provide information to someone involved in your care

 

5.      any letters or documents that are written to me by you or by anyone involved in your care

 

6.      a copy of all letters that you have authorized me to write to insurance companies, health care professionals, employers, etc.

 

7.      a copy of each invoice that you receive at the time of your appointment

 

8.      a copy of all insurance forms that I have completed

 

9.      the answer sheets, and results from all questionnaires that you completed

 

10.  a copy of the signed Consent to Treatment form

 

 

CONFIDENTIALITY AND THE LIMITS ON CONFIDENTIALITY

 

As a Psychologist, I have the ethical responsibility to protect your confidentiality.  This means that, whenever I can legally do so, I will keep private the information that you give to me.

 

To make sure that your confidentiality is protected, I will not release information to anyone unless I have your written permission to do so.  This means that if someone (e.g., a family member, insurance company, physician) telephones or writes to me asking for details about you, I cannot provide ANY information to him/her without your WRITTEN permission to do so.  This applies even if I know that you are being cared for by the agency or person who contacts me.  You may withdraw permission to release information at any time by simply informing me that you wish to withdraw consent.

 

For all Psychologists, there are limits on confidentiality.  You need to be aware that there are times when I cannot promise to keep information private.  The following are examples of circumstances in which I may have to break my promise of confidentiality.

 

1.    If I feel that you are going to commit suicide, I must contact someone who can protect you from carrying out your plan.

 

2.    If you indicate that you are going to harm someone else, I must let that person and the authorities know that he or she is in danger.

 

3.    If you tell me about any child abuse case that has not already been brought to the attention of authorities, I must contact appropriate people (e.g., Children’s Aid Society) in the area where the accused lives.  Historical child abuse (in which the child is now over the age of 16) is excluded from this requirement.

 

4.    If you tell me that you have been sexually abused by any licensed health care professional in Ontario, I am obliged to report the alleged abuser to the college that governs that person.  You, as the client, can choose to remain anonymous.  The law obliging me to report applies to 15 groups of professionals such as physicians, nurses, psychologist, chiropractors, dentists, midwives, and occupational therapists.

 

5.    If my file about you is subpoenaed by a Court, I am obligated to provide them with a copy of my entire file or any part that they wish to have.  I can also be subpoenaed to provide testimony.

 

CONSENT TO TREATMENT

 

By signing this form, you confirm that you have read the information provided on the four previous pages, that you understand my office policies and the limits on confidentiality as listed, and that you agree to provide information to me under those conditions.

 

I have read the description of Office Policies as well as Confidentiality and the Limits on Confidentiality.  I understand them and have had an opportunity to discuss any questions with Dr. Wieland.

 

I agree to these conditions and wish to begin therapy.  I understand that I can proceed with therapy at my own pace, and can discontinue at any time.

 

 

 

 

__________________________________        _____________________________

Signature of Client                                           Linda D. Wieland

 

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