CONSENT & FEE AGREEMENT

Psychosocial Interventions 

Consent to Engage in Professional Social Work Services

This document represents my voluntary and informed consent to participate in professional social work services, specifically within the context of a psychosocial interview.

• I acknowledge that I may withdraw from social work services at any time. I also understand that all information and records will be maintained in a secure and confidential manner.
• I understand that if I was referred by a third party (e.g., a fertility clinic or consultant agency), a summary report will be prepared following my session with Your Counselling Ltd. This report will be shared with the referring party. Once transmitted, the summary report becomes the property of the receiving clinic or agency, and any further disclosures will adhere to their policies.
• I understand that Your Counselling Ltd. does not retain formal copies of the summary report, keeping only intake notes and relevant information. The summary report will be sent to the clinic or agency as a PDF document attached to an email. I release Your Counselling Ltd. from any liability associated with the electronic transmission or disclosure of this report.
• I understand that if I wish to obtain a copy of the summary report, I must request it directly from the referring agency or clinic, following their established processes and procedures.
• We consider any appointment that you have made important. Your appointment is for your exclusive use and when it is cancelled with short notice, or missed altogether, it is too late or impossible to offer this time to someone else and the appointment time goes unfilled.
• A full 24-hour notice period is required for cancelling appointments.
• Confirmation from either our booking system or our admin team is required for confirm a session has been successfully cancelled.
• If you cancel with less than 24 hours before your appointment time, you will be billed for 100% of the cost of your appointment.
• Clients who fail to show up for a scheduled appointment (“no show”) are billed/invoiced for the full cost of their scheduled session.
• Our booking system will send out reminder emails. These reminders are a courtesy only; clients are responsible to keep or cancel their appointment regardless of whether they receive a reminder or not.
• If you are uncertain when your next appointment is, please call our office.

• There is a range of valid reasons for cancelling an appointment. To be consistent with all clients, cancellation fees will only be waived in the event of a documented medical emergency requiring urgent professional treatment, a death in the family or unsafe weather for travelling (i.e. severe snowstorm).

• Missed appointments and late cancellations are payable via debit, credit, cash or e-transfer prior to your next session.

• All no-show fees or cancellations fees collected have receipts marked “cancellation fee” or “missed appointment” and cannot be marked as a “counselling session”.
• We are unable to direct bill your insurance for any late cancellation or no show appointments.
• Weekend Appointments must be cancelled by the Friday before the appointment occurs.
• Clients with overdue invoices and funds owned are not able to book sessions.
• Any unpaid accounts may be referred to a third-party collection agency for recovery. To avoid this, we encourage timely payment or to contact us to discuss payment arrangements.

FEE STRUCTURE

Parenting Consultation/Family Counselling:  $ 200.00 per 60. min session*.

Third Party Reproduction: Based on contracual arrangment with referring agnecy

Documentation fees may apply and will be discussed in advance of completing any reports or clinical documentation.

Fees for extended sessions are billed in 15-minute increments.

By placing my electronic signature below, I acknowledge that it holds the same validity as a signature provided in person. I also understand that this consent will be reviewed verbally before any social work intervention begins. I confirm that I can raise any questions about this consent prior to the interview.