Contact Information:
Telephone #: 613 599-0937
Email address: kpc@genian.net

Kanata Psychotherapy Centre’s Privacy Policy for the Consent to be Treated

Dear Client,
Your informed consent is needed for the services that are to be provided. To protect your rights before giving consent the Privacy Policy of Kanata Psychotherapy Centre is outlined in terms of protection of your personal information, cost, and quality assurance.  Please ask any questions you might have.

Privacy of personal information is an essential principle to this practice. Your right for confidentiality is respected at all times. Personal information is collected and used responsibly and ethically in accordance with the requirements of The College of Psychologists of Ontario.

The only exceptions to your right for confidentiality are legal obligations that I have as a registered psychological service provider:

Protecting Personal Information:

You are always free to choose to participate in therapy or not. Psychotherapy procedures are discussed after the evaluation period to ensure you understand the benefits, risks, and alternatives.

Please take notice that Jayni Bloch will not participate in any legal proceedings related to your life. Our contact is for psychotherapy and not legal work in any form or other.

Correspondence between the Service Provider and the client is necessary form time to time. You agree to receive and send email correspondences to this Practice.

Office hours are 1pm. to 6 pm. unless differently specified.
Sessions are approximately 50 minutes long.
10 minutes in the hour are used for administrative activities.

Psychotherapy is most effective when made a priority and should not be cancelled lightly. You have the right to terminate therapy at any time, however, please discuss your reasons or intention to terminate with this practice.

Psychological services are not covered by the provincial government but can be reimbursed by private insurance plans and may be tax deductible.
Payment of services is due at each session by Cash, Cheque, or e-transfer after we agree on an access code.
Clients are responsible for the penalty fee of $20 with each “Non-Sufficient-Funds” cheque, on top of outstanding money.

 Fee adjustments are made every year according to College recommendations.

I can be contacted at my office in the case of an emergency during office hours.
If I cannot be reached, the Emergency Department of any General Hospital with a Psychiatric facility should be contacted.

After evaluating your circumstances, I reserve the right to refer you to a colleague for psychological services, when my own scope of practice is not appropriate to deal with your particular problem. You have an equal right to be referred, if you feel I am not the appropriate service provider for you.

Consent
I (print your name) ………………………………………………………………………………
give Jayni Bloch consent to provide me with professional psychological services 

I understand the private policy and conditions of this practice as explained above.

 

Signature of Client: _______________________________Date: _________________

Signature of service provider: _______________________Date: _________________