Forms for 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.

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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.