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Counselling Intake & Consent

Preferred method of communication
Are you currently experiencing difficulties with any of the following?
Do you consider yourself a spiritual or religious person?
Yes
No
Unsure
Do you / your partner have insurance that covers Masters level Social Work Services?
Yes
No

Therapy Fee Agreement

Appointments last between 50 and 60 minutes and end as scheduled. If you're late, we'll still finish at the original time to respect everyone’s schedule. Sessions are currently billed at the rate of $130 per session however, if you do not have extended benefits, please notify me and we can discuss adjusting payment to meet your needs.


Cancellations

Please cancel any appointment at least 24 hours in advance. If you cancel less than 24 hours before your session, a $40 fee will be charged for the time spent planning your session. Exceptions may be made for emergencies at my discretion.


Payments via e-transfer or cash must be made before the start of each session. This contract is solely with Amber Raymond, BSW, MSW, RSW. I am an independent practitioner and am not liable for any other practitioners or groups in this office or building.


By signing below, you acknowledge your payment responsibilities and accept the terms of this contract, constituting informed consent for therapy with Amber Raymond, BSW, MSW, RSW.

Social Work Informed Consent


This information outlines what you can expect from my counseling services and details how your personal information will be collected, used, and protected. As a registered Social Worker, I am dedicated to safeguarding your privacy and have established policies in line with the Personal Information Protection and Electronic Documents Act (PIPEDA) and the Personal Health Information Protection Act (PHIPA).


Please ensure that you agree with the following statement prior to signing at the bottom of the form.

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