Intake, Limits of Confidentiality and Consent to Treatment Provided by Camille Hadida

The information you provide in this form will be part of your confidential records as governed by the College of Registered Psychotherapists of Ontario’s Record Keeping Standards of Practice. Your information will be sent directly to us via email and will not be stored on any servers.

Name *

First

Last

Date of Birth (MM/DD/YYYY): *

Marital Status *

Email *

Confirm Email

Home Address *

Address 1

Address 2

City *

State / Province *

Zip / Postal Code *

Country *

Preferred Telephone Number *

Emergency Contact Name *

First

Last

Emergency Contact Telephone Number

Relationship to you *

Psychotherapy Treatment Description *

Please check here to confirm that you have read, understand and acknowledge the service description: I understand that Camille Hadida (the therapist) will be providing me psychotherapeutic services in her role as a registered member of the College of Registered Psychotherapists of Ontario. I understand that Camille Hadida is also registered with the College of Chiropractors of Ontario and the College of Vocational Rehabilitation Providers. However, she will not be providing services under her registration with these regulatory bodies during my psychotherapeutic sessions.

Consent to Treatment and Limits of Confidentiality *

Please check here to confirm that you have read, understand and acknowledge the limits of confidentiality and that you consent to treatment with this knowledge and understanding: I understand that my information is maintained confidentially and will not be released to a third-party without my informed consent, with the following exceptions: • If I am considered to be an imminent threat to my physical safety or to the safety of others. • If there is suspicion of child abuse or neglect. • If I was abused by a member of a regulated health profession. • If a court orders the disclosure of records. • If I report abuse of an elderly person by staff in a long-term care facility. • When insurance companies inquire about the dates of services and fees. I understand that I have the right to withdraw my consent for psychotherapy services at any time with written notice to the therapist.

Benefits and Risks of Treatment *

Please check here to confirm that you have read, understand and acknowledge the benefits and risks of treatment: I understand that psychotherapy can entail benefits, such as finding new coping strategies and problem-solving techniques and experiencing positive personal changes and it can entail certain risks, such as eliciting difficult or distressing emotions or personal changes that can impact relationships. I understand that there is no guarantee that psychotherapy will be successful in achieving my treatment goals. I understand that it is important that I promptly advise the therapist of any concerns or questions that I may have at any time during the process of therapy.

Payment for Services and Fee Agreement *

Please check here to confirm you have read, understand and acknowledge the fee agreement and cancellation policy: I understand that the fee for all psychotherapy services provided to me is $150.00 (including HST) per 50-minute session. I agree to pay for these services at the beginning of the session. I understand that additional fees are subject to the time and nature of the services involved. Written reports, letters, other forms of written correspondence, court attendances (including commute and wait times), phone conversations, and phone consultations with other professionals will be billed based on the above-noted rate. I acknowledge the two business days cancellation policy. If I am unable to attend my appointment for any reason, I will notify the therapist two business days in advance, otherwise, I will be charged the full amount for the session.

Video-based Therapy and Electronic Communications *

I have read, understand and acknowledge the electronic communication policy below. I AGREE to engage in video therapy.

Electronic Communication Policy: While we make every effort to ensure your confidential information is protected, there are some factors beyond our control with respect to confidentiality when using electronic media, such as when communicating through emails and text messaging, or when engaging in video or telephone sessions. Therefore, it is our policy to limit communication via email and text messaging for the purpose of scheduling or clarifying procedures, policies and payment details. Regarding video or phone-based therapy, I understand that it is not the same as a direct client/therapist visit because we will not be in the same room. There are potential risks to using online technology and telephonic communication, such as technology interruptions, unauthorized access by a third-party and other potential technical difficulties. Either my therapist or I have the ability to discontinue video or phone-based therapy if it is felt that the connection is not adequate for the situation. I understand that prior to starting video therapy I will be provided information on how to access the therapy session and I may ask questions about how to do so prior to starting the session. I have the right to discontinue or withdraw my consent for video or electronic forms of communication, by providing written notice. I understand that I have the opportunity, either before, or after the start of treatment, to ask any questions pertaining to electronic communications and video therapy.

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