THERAPIST-CLIENT TREATMENT CONTRACT

Welcome to our practice. This document contains important information about our professional services and business
policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next
meeting. When you sign this document, it will represent an agreement between us.

PSYCHOLOGICAL SERVICES

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist
and client and the particular problems you bring forward. There are many different methods I may use to deal with the
problems you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort
on your part, similar to the effort and practice involved in learning any new skill. In order for the therapy to be most
successful, you will need to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life you
may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other
hand, psychotherapy has also been shown to have significant benefits for people who go through it. Therapy often leads
to better relationships, solutions to specific problems, and a significant reduction in feelings of distress. There is no way
to guarantee what your experience will be.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation I will be able to offer you
some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy.
You should evaluate this information along with your own opinions of whether you feel comfortable working with me.
Therapy involves a commitment of time, money and energy so you should be careful about the therapist you select. If
you have questions about my procedures we should discuss them whenever they arise. If your doubts persist I will be
happy to suggest another mental health professional for you to consult.

MEETINGS

I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the best
person to provide the services you need in order to meet your treatment goals. If we decide to proceed with therapy we
would schedule appointments at whatever frequency we decide on (e.g., weekly, biweekly, monthly). Sessions are 50
minutes long.

PROFESSIONAL FEES

As of March 18, 2019

The hourly fee for individual counselling from a registered psychologist is: $200.00.

The hourly fee for for family and couples counselling from a registered psychologist is: $230.00.

Fees are normally collected at the end of each session and receipts are available. If you have extended health benefits
you can submit your receipts for direct reimbursement from your insurer. It is your responsibility to pursue reimbursement
from your insurer.

In addition to appointment fees you will be billed at the above mentioned hourly rate for other professional services you
may need such as report writing, completion of insurance forms, telephone or email communication which accumulates
to more than ten minutes over the course of a week, attendance at meetings with other professionals you have
authorized, preparation of records or treatment summaries, and time spent performing any other service you may request
of me. If you are or become involved in legal proceedings requiring my participation you will be expected to pay for my

Revised: March 18, 2019

professional time. The fee for legal reports, consultation with legal representatives, and expert testimony is $200.00 per
hour.

Our cancellation policy requires you to provide 48 hours notice. If you miss an appointment without providing notice you
may be billed for the missed session.

If you miss a scheduled appointment without calling to cancel, any pre-booked appointments may be cancelled without
notice by your therapist. Your therapist may request payment for the missed session(s) prior to re-booking new
appointments.

For clients whose counselling fees are covered by a third party (e.g, WSIB, motor vehicle insurer, Criminal Injuries
Compensation etc.) please note that these payers do not pay for missed appointments and you may be responsible for
direct payment of session costs for appointments missed or cancelled without sufficient notice.

If you are receiving psychological services as part of your accident benefits with a motor vehicle insurer, please note that
when your accident benefit claim is settled with your insurer, the insurer is no longer responsible for payment of treatment
sessions, even if there are sessions remaining on a preexisting treatment plan. It is your responsibility to inform us
regarding any settlement meetings with your insurer so that session fees can be submitted for payment to your insurer.
If your file settles and you continue with treatment, you are responsible for the costs of treatment sessions subsequent
to the date of settlement.

Please note that we reserve the right to pursue unpaid accounts through the use of a collection agency or small claims
court. In most collection situations the only information we release regarding a client’s treatment is his/her name, the
nature of services provided, and the amount due.

CONTACTING ME

I am not usually available immediately by telephone. I monitor my voice mail messages regularly throughout the day and
will return your call as soon as I am able. If you are difficult to reach, please leave times and numbers when you will be
available. I do not normally make calls or check messages on evenings, weekends or holidays. If you are calling and
it is an emergency, you are welcome to use my home number if we have pre-arranged this as part of a safety plan.
Otherwise, you can contact your family doctor or a crisis service. See below for some crisis service phone numbers.

Assaulted Woman’s Helpline (866) 863-0511

You have the right to ask questions about anything that happens in therapy. I’m always willing to discuss how and why
I’ve decided to do what I’m doing and to look for alternatives that might work better. You can feel free to ask me to try
something that you think will be helpful

You are free to leave therapy at any time. If either of us feel I do not have the skills or expertise to help with your
particular problem I will be pleased to provide you with names of other local professionals.

LIMITS OF THERAPY

There are some circumstances under which I may choose to terminate therapy.

Therapy will be terminated if there are any verbal or physical threats or acts of violence/harrassment towards myself,
the office or my family.

I require that you inform me of any legal involvement you may have at the time of our initial meeting. This is important
since my file may be requested or I may be asked for an opinion by legal professionals involved in your case. If you do
not disclose this information at the assessment/evaluation stage then I reserve the right to terminate treatment.

Revised: March 18, 2019

I reserve the right to terminate treatment if there is pattern of missed or cancelled appointments.

If your treatment costs are paid by a motor vehicle insurer or the workplace safety and insurance board, funding for
treatment is contingent on approval from these insurance sources. There are times when the insurer refuses to pay for
further treatment although you may wish to continue. On these occasions, you can decide if you would like to continue
with treatment and pay for treatment yourself. Alternatively, we can help you identify other mental health services whose
costs are covered (e.g., psychiatrist, funded mental health agency).

ACKNOWLEDGMENT

I have read this document and have had sufficient time to be sure that I have considered it carefully, asked any
questions that I needed to, and understand it. I agree to abide by its terms during our professional relationship.

Please sign here to indicate that you have read and understood the above.

Signature Date

Revised: March 18, 2019