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Counseling Agreement and Fee Schedule

Counseling fee is $150/hour payable at the time of service. This office does not direct bill, therefore you will have to claim this expense on your own to your service provider if you have one. A receipt will be provided to assist you in this.

As a courtesy to both the counselor and other clients, if you cannot make your appointment, please provide at least 24 hours notice of cancellation. A $25 fee will be charged for missed appointments that have not been cancelled. Emergency situations will be taken into consideration.

I understand that counseling services provided are confidential, except where there is harm to self (suicide) or harm to others (assault or homicide) is a present concern. There is an ethical duty for your counselor to notify individuals that may assist you when self harm or harm to others may be a concern. The appropriate individuals (doctors, family members or RCMP) will be notified for your safety.

If you request that information be provided to or collected from another party, a written consent to disclose or collect information will be required.

I have read the above counseling conditions, understand what I have read and agree to the above conditions.