I give consent to receive Speech-Language Pathology (SLP) services (including assessment, intervention, and/or consultation). I understand that this consent will be valid I am discharged from therapy. Should there be a significant change to my program, I understand that I will be advised of this change by telephone, e-mail, or in person.
❏ I understand that I may withdraw my consent at any time.
❏ I understand that should the primary speech-language pathologist for my child need to change, the new speech-language pathologist will contact me.
❏ I understand that the SLP may confidentially consult with other professionals without using my personal health information. This may involve sharing relevant information to ensure greater progress.
I understand that my conversations with my therapist (SLP) are confidential. However, I also realize that there are specific situations in which client/clinician confidentiality cannot be assumed. These include:
1. Danger to Self. If I pose a danger to myself such that I am seriously suicidal, my therapist will disclose information about me and my condition as necessary to authorities in order to prevent me from harming myself. I understand that only information relevant to the purpose of keeping me safe will be disclosed.
2. Danger to Others. If I pose a danger to others, I understand that my therapist is ethically bound to protect anyone to whom I present a clear and imminent danger. If I make specific threats of violence against an identifiable person, my therapist will attempt to protect the potential victim by making an effort to warn them by contacting police.
3. Child Abuse. My therapist is required to report to authorities any suspected case in which a child may be being abused. It does not matter how much time has elapsed since the occurrence of the abuse; if the victim is still a child , my therapist must report the incident. If I am an adult and disclose past child abuse, and my psychologist has reason to believe that the abuser is still victimizing children, my therapist is obligated to report that suspicion.
4. Driving. If I hold a driver’s license but it is apparent that I am not fit to operate a motor vehicle my therapist is obligated to report this to the department of motor vehicles.
5. Group therapy. If I am being seen in a group, the confidentially of anything that is said cannot be guaranteed, but promised by other members of the group.
6. Court Orders. I understand that my therapist can be ordered to present their notes to the court. My therapist will comply with a court request or order for notes only after attempting to protect the privacy of any client information.
7. Third Party Payment. I understand that if a third party (e.g. extended health insurance) is paying for the services I receive, the third party will be informed of only that information this is required for payment of my therapist. If a third party requires a report about my claim, only information relevant to my claim is reported.
CLINIC FINANCIAL POLICY
I agree to the following:
! Charges are based on a clinical hour defined by insurance providers as 50 - 55 minutes with the clinician.
! Our usual hourly fee is applied for a failed appointment without 24-hour notice of cancellation. This charge is not paid by insurance.
! Other billable services including phone calls, review of records, consultation with clinicians, attorneys or others at the client’s request, and any other professional services, either requested by the client or necessary for treatment, but outside of the clinical face-to-face setting are usually the responsibility of the client. These other services are charged on a quarter-hour basis.
! The client hereby authorizes payment of insurance benefits to this office for services rendered for the client and/or their dependents.!
! The client acknowledges that the clinic is not responsible for insurance company’s denying a claim. Clients are recommended to contact their insurance provider for clarification around policy coverage.
! The client acknowledges that financially responsible to this office for all copayments and charges not covered by the assignment of benefits above.
! It is the office policy to collect payment directly from the client at the time of the appointment.
! Redeemed sessions are non-refundable.
! Pre-paid account credits are refundable if the session has not occurred. Account credits will be
calculated using the regular sessional rate if the block was interrupted.
! Credit card payments are subject to a 2.8% administrative fee
! Cheques can be used to prepay sessions or to pay for sessions on a weekly basis.
! Cash payments are also accepted. However, the clinic does not carry change.
! Invoices are generated and issued on Tuesdays and Thursdays.
Public Statement – Personal Health Information
Confidential personal health information is protected by the Personal Health Information Protection Act (PHIPA) at Well Said: Toronto Speech Therapy (WS-TST). The Act ensures that the personal health information of our clients is secure, safe, and confidential by governing its collection, use and disclosure.
Personal health information is collected, disclosed, and used by Well Said: Toronto Speech Therapy with informed consent, and only in circumstances when the information is necessary to provide an effective clinical service delivery. A client may withdraw consent at any time by providing notice to WS-TST. WS-TST safeguards personal health information to protect against unauthorized use, disclosure, copying, modification, and unauthorized use including theft and loss.
Contact Person: Individuals should direct any inquiries or complaints pertaining to personal health information to Melissa James via mail: 670 Bloor Street West; Suite 201, Toronto, Ontario, M6G 1L2.
Access to Records: A service participant of WS-TST can request access to his or her record of personal health information. Requests should be provided in writing to the Contact Person. In compliance with PHIPA, records will be made available within thirty days.
Complaints regarding the use, collection, disclosure, modification, retention or disposal of personal health information should be submitted in writing to: Information and Privacy Commissioner/Ontario 2 Bloor Street East Suite 1400 Toronto, Ontario M4W 1A8