Supervision Form

Supervision Consent

who is my son/daughter.

Professional Qualifications

Office Hours

Office hours are normally 9 a.m. to 5 p.m., although some late afternoon or early evening appointments are available. Counselling interviews consist of 2 units, each 25 minutes in length. Sessions will vary in length according to need.

Insurance Coverage

Psychological services are not covered by O.H.I.P., but are often partially or fully covered by extended insurance plans (e.g., Blue Cross etc.). Various plans differ, so please check with yours regarding coverage and claim procedures (e.g., whether or not a letter or referral from your physician is required, details required on receipts etc.). Referrals need only state,
for psychological consultation or assessment.”

Payment for services

Payment for services is due at the end of each session and a receipt will be given when payment is received. Please retain this receipt for your insurance or income tax claims, if applicable. Fees vary according to the time and nature of the service involved. All fees charged follow the guidelines set by the Ontario Psychological Association (O.P.A.) for psychological consultation and counselling. Generally clients pay for their sessions at the end of each visit. In this way, the account remains manageable and counselling becomes a naturally budgeted expense. Your fee will be discussed with you during the intake interview and you will be advised beforehand if any changes are made to the fee. Fees may be paid by cash, cheque, or VISA. A surcharge of $10.00 will apply to all N.S.F. cheques.

Cancelled and Missed Appointments

In order to maximize the effectiveness of psychological services, clients should make counselling a high priority and should not cancel sessions except in cases of emergency. Session fees will be applied for appointments cancelled less than 24 hours in advance.


Confidentiality is respected at all times. No information will be communicated, directly or indirectly, to a third party without your informed and written consent. Exceptions to confidentiality include the legal, and/or ethical obligations to:

  • Inform a potential victim of violence of a client’s intention to harm
  • Inform an appropriate family member, health care professional, or police if necessary of a client’s intention to end his or her life
  • Release a client’s file if there is a court order to do so
  • Inform the Children’s Aid Society if there is suspicion of a child being at risk or in need of protection due to neglect, or physical, sexual, or emotional abuse
  • Report a health professional who has sexually abused a client

In Case of an Emergency

I have read and understood the information presented in this document, and hereby consent to psychological treatment and/or assessment

Informed Consent

I have read and understood the information presented in this document, and hereby consent to psychological treatment and/or assessment