consent to online psychology

All clients who wish to receive online psychology services are required to review the following consent form and agree to the terms and conditions outlined within.

Important Information

This form is to document that I (named below) give permission and consent to Nicole McCance, M.A., C. Psych., who is a Registered Psychologist to provide psychological consultation, assessment, and/or treatment to me. I give permission and consent to my treating therapist at New Roots Therapy (named below) to provide psychological consultation, assessment, and treatment to me.

Psychological Services

Therapy is not like a medical doctor visit. In order for it to be most successful, I will have to work on things I talk about both in session and between sessions. Since therapy involves discussing unpleasant aspects of my life and making changes in my beliefs or behaviours, I may experience uncomfortable feelings and changes to my relationships. Therapy can have benefits and risks. There are no guarantees in therapy. I have the right to ask questions about anything that happens in therapy. I have the right to refuse anything my treating therapist suggests. I can ask my treating therapist to try something that I think might be helpful. I am free to leave therapy at any time. I understand that sometimes it will be easy for me to come to a session and other times I will think about cancelling a session even though I can come to it. I will do my best to push through this common type of resistance, understanding that it is part of the therapy process.

In Case of an Emergency

Emergency services are not available. In the case of an emergency, I should dial 911, contact a mobile crisis unit, call my local distress centre, contact my family doctor, or go to the emergency department of any hospital.

Professional Qualifications

I understand that Nicole McCance, M.A., C. Psych., is responsible either directly or through my treating therapist at New Roots Therapy for all aspects of the psychological services provided to me when Nicole McCance is supervising my case. I further understand that my treating therapist is not a doctor and is not registered with the College of Psychologists in Ontario, but has the required training to deliver psychological services under the supervision of a Psychologist. If I wish to speak with Nicole McCance, I may do so by calling her main office at (416) 619-0442 to make those arrangements. When necessary, it is possible for a meeting to be arranged with Nicole McCance at my request, at my treating therapist’s request, or at Nicole McCance’s request.

Documentation of Diagnosis, Prognosis, Health or Disability Status

I understand that should I require documentation (i.e., letter, report, or form completed) for my records or for any third party that offers an opinion, prognosis, or diagnosis of my condition, I will need to meet with Nicole McCance and pay the fee that is associated with this consultation. I understand that I may be required to travel to Nicole McCance’s office for this consultation.

Insurance Coverage

Psychological services are not covered by O.H.I.P., but are often partially or fully covered by extended insurance plans (e.g., Manulife). Various plans differ, so I will check with mine regarding coverage and claim procedures (e.g., whether or not a letter or referral from your physician is required, details required on receipts, etc.).  

Payment for Services

Fees vary according to the time and nature of the service involved. All fees charged follow the guidelines set by the Ontario Psychological Association for psychological services. I understand that payments for online psychology services are processed on the day of my appointment using the credit card information that I provided at the time of intake. In this way, the account remains manageable and therapy becomes a naturally budgeted expense.  

I will discuss the therapy fee with my treating therapist and/or their office staff before my first session and I will be advised before any changes are made to the fee. A receipt will be given after payment is received. I will retain my receipt for my insurance or income tax claims, if applicable. 

Cancelled and Missed Appointments

In order to maximize the effectiveness of psychological services, I will make therapy a high priority and will not cancel sessions except in cases of emergency. If I cancel with less than 24 hours’ notice in advance or miss a scheduled session, I will be charged the full fee for that session. If I am late for a session, I understand that we will use the remaining time in our scheduled session and I will be charged the full fee for that session.

Privacy of Personal Information  

Nicole McCance Psychology uses a treatment team approach. Some or all of the services delivered to me will be supervised by a regulated health professional, Nicole McCance. My treating therapist, the clinical supervisor (Nicole McCance), and a secondary clinical supervisor (Leanne Wagner, Registered Psychological Associate) will have access to my clinical file and personal information for treatment purposes. I understand that in order for Nicole McCance, Leanne Wagner, and my treating therapist to provide me with psychological services, they will collect some personal information about me. I understand that I have the right to review and the right to a copy of my personal information, barring a few rare exceptions. I understand that my clinical file may be kept both in electronic form and/or in hard copy and Nicole McCance, Leanne Wagner, and my treating therapist will have access to my file. This file must be retained in a secure location for a minimum of 10 years after the last date of contact. I understand that you may also use office staff, consultants, and agencies that may, in the course of their duties, have limited access to my personal health information. These may include computer consultants, office security and maintenance, bookkeepers and accountants, lawyers, temporary workers to cover holidays and office administration, credit card companies, practice management solution providers, suppliers of cloud technology such as internet faxing, email and web hosting, and cleaners. Their access to any personal information will be granted only on an as-needed basis governed by appropriate privacy principles.

Email Policy

I understand that e-mail is not a secure form of communication and electronically submitted information is not 100% secure.  If I decide to communicate with Nicole McCance, another practice associate or staff member, or my treating therapist by e-mail, I will limit e-mailed information to that which I would be comfortable discussing in a public place. I understand that I am responsible for safeguarding any electronic communications I download, print, or access and I will not forward, give, or copy (in whole or in part) email messages or electronic communications from my treating therapist to any other person, except with the prior written agreement of my treating therapist.

Confidentiality

Confidentiality is respected at all times. No information will be communicated, directly or indirectly, to a third party without your informed and written consent, unless required by law. It is important to understand that confidentiality for online psychology cannot be guaranteed in the same way as confidentiality for in-person sessions (e.g., someone could overhear your conversation, etc.). Your treating therapist takes measures to protect your confidentiality during online therapy sessions by using a platform which adheres to all Canadian privacy protection legislation and working from a private, distraction-free environment.

Nicole McCance and your treating therapist practice in the province of Ontario and are required to abide by Ontario safety standards, even if those standards are different in your location. Exceptions to confidentiality include the legal and/or ethical obligations to:

  • Inform a potential victim of violence of a client’s intention to harm

  • Inform an appropriate family member, health care professional, or police, if necessary, of a client’s intention to end his or her life

  • Release a client’s file if there is a court order to do so

  • Inform the Children’s Aid Society if there is suspicion of a child being at risk or in need of protection due to neglect, or physical, sexual, or emotional abuse

  • Report a health professional who has sexually abused a client

  • Share information with Nicole McCance, another practice associate, or the College of Psychologists of Ontario for supervision or auditing purposes

  • In the case of family counselling, when a session is held without all family members present, information shared in that session will not be held as confidential when the family sessions resume

By filling out and submitting the Consent to Online psychology response form below, you indicate that you understand the terms of service as outlined above and that you voluntarily agree to receive therapy under the above terms.

Person #1
Name *
Name
Birth Date *
Birth Date
Person #2 (if applicable)
Name
Name
Birth Date
Birth Date
Treating Therapist *
Please check the name of your treating therapist at New Roots Therapy
Informed Consent *