Name 1
*
First Name
Last Name
Name 2
*
First Name
Last Name
Date of Birth 1
*
MM
DD
YYYY
Date of Birth 2
*
MM
DD
YYYY
Occupation 1
Occupation 2
Email 1
*
Email 2
*
Address of Residence 1
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Address of Residence 2
If different from above.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Phone Number 1
*
(###)
###
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Primary Phone Number 2
*
(###)
###
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Emergency Contact Person
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First Name
Last Name
Relationship to You
*
Email
*
Phone Number
*
(###)
###
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Who Referred You to Me? Or, How Did You Find Me?
Limits of Confidentiality
*
Everything you share with me is confidential. However, there are a few exceptions. As a professional, I am required by law to disclose confidential information if any of the following circumstances applies:
1. If you plan to harm yourself or another person, I may inform medical or law enforcement personnel.
2. If you disclose to me knowledge of physical or sexual abuse of a minor child by an adult, or of an elderly or disabled person, I am required to inform the appropriate agencies.
3. If you disclose the sexual misconduct of a mental health professional, I am required to report it to the appropriate College.
4. If you become involved in a legal case (child custody, civil suit, criminal etc.), I may be required to produce records or testify.
I will do everything I can to keep your records confidential but sometimes it may be out of my control. If you have any questions about these limitations, please discuss them with me.
Consent to Psychotherapy
*
We take full responsibility to inform our therapist, Wendy Sun, about any physical, mental or emotional conditions that may affect our receiving therapy. We understand that this work does not constitute medical treatment but rather is a form of health maintenance using the techniques of Psychotherapy/Counselling and that our licensed Medical Doctor is my primary source of health care. We have discussed all questions with our therapist, Wendy Sun, and our acknowledgment below constitutes informed knowledge authorization and consent to receive therapy.
Payment for Services
*
We agree to pay for 75 minute couples/family therapy provided to us at the rate of CAD $180 + HST.
We acknowledge that we understand that the fees may increase periodically and the therapist, Wendy Sun, will provide a minimum of 60-days-written notice prior to any fee increases.
Your payment options are:
Interac Email Money Transfer to sunwendy@rogers.com
Credit card through Square (additional fee applies)
Fees may vary according to the time and nature of the service(s) involved and you will be advised in advance if any changes are made to the fee.
Cancellation Policy
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There is a 24-hour cancellation policy. If you cannot attend your appointment, please notify me 24 hours in advance, otherwise, you will be charged the full amount of the session.
Video Therapy
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We agree to engage in video therapy when applicable.
We understand that video conferencing technology will be used. We understand that such a consultation will not be the same as an in-person visit due to the fact that we will not be in the same room as our therapist.
We understand there are potential risks to using online technology such as interruptions, unauthorized access by the third party, and potential technical difficulties. We understand that Wendy or we can discontinue the use of video therapy sessions.
We have had the opportunity to ask questions prior to the session by booking a free 20 minute consultation online or over the phone, email and/or scheduling a phone call prior to the video session.
