This document provides information about psychotherapy services provided online and in-person by Orangebloom Therapy & Counselling, what the service entails, the cost involved, and what we do with the personal information obtained about you. If you have any questions about any of this, please do not hesitate to ask.
Orangebloom Therapy therapists are using an online platform which adheres to all Canadian privacy protection legislation and is a fully PHIPA compliant video service.
The therapist is conducting video sessions in a private, distraction free environment.
The client is responsible for securing his or her own computer hardware, internet access points, and password security.
Orangebloom therapists are not liable for confidentiality breaches when they are caused by client’s error.
Orangebloom therapists are not responsible for their client’s equipment failure, e.g. camera, and/or Internet service.
Therapists are not responsible for lapses in confidentiality that are in direct response to the client’s actions.
There may be additional charges from client's internet/telephone provider for exceeding data limits and/or phone minutes while using e-Counselling or telephone for this service. Please check your data / phone limits to ensure you do not incur unexpected overages.
Clients do not have to pay any additional charges to use the link to the video platform sent to them by their therapist.
Telehealth session will not be audio or video recorded at any time and that we will both disable computer and device-generated recording to the best of our abilities.
If video services are not available due to an unplanned equipment or service malfunction, sessions will occur via telephone on a phone number the client has provided for such purposes.
Your therapist practices in the province of Ontario and is required to abide by Ontario safety standards, even if these standards are different in your location.
Online therapy is not a crisis based clinical service.
Online therapy may not be appropriate for clients with active suicidal or homicidal thoughts, or clients who are experiencing acute mental health problems, such as manic or psychotic symptoms.
It is the responsibility of the client to inform their therapist if they are at risk of harm to self or others.
At intake, a client who reports being at risk of harm to self or others, will not be offered online psychotherapy from Orangebloom Therapy but will be referred to in-patient treatment.
If through the intake evaluation or subsequent psychological therapy sessions a client is deemed to be at risk of harm to self or to others, Orangebloom Therapy will terminate the sessions, while providing alternative referral suggestions.
If a client who was not formerly at risk, should become at risk of such harm to self or others, they must immediately report it to their therapist. In such cases, a client may be referred to crisis services such as their family doctor, urgent care clinic or emergency department at the nearest hospital.
If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in tele-psychological assessments/psychological therapy sessions.
I understand that for Orangebloom Therapy & Counselling to provide me with psychotherapy services, some personal information will be collected about me (e.g., name, address, telephone number, health history, and social situation) in order to help assess what my needs are. This information will then be used to advise me of my treatment options and to help me receive the treatment that I choose. I understand that in the course of business, office staff may need to access some of my personal information (e.g., address for billing purposes, extended insurance information) and that this access is limited.
I understand that I have the right to review and the right to a copy of my personal information, barring a few exceptions. I agree to Orangebloom Therapy collecting, using and disclosing personal information about me.
Information about the client will only be released with his or her express written permission, with the exceptions of the following cases:
•If the therapist determines risk of self-harm
•If the therapist determines risk of harm to others
•If the therapist is informed about or suspects abuse, neglect, or exploitation of a minor or of an incapacitated adult
•If the therapist believes that someone’s mental condition leaves the person gravely disabled
•Release a client’s file if there is a court order to do so
•Report a health professional who has sexually abused a client to the professionals regulatory College
The laws that protect the confidentiality of any medical information also apply to online psychological assessment/psychological therapy. I understand that the limitations to confidentiality also apply to the videoconferencing format.
The therapist will maintain records of online and in-person counseling and/or consultation services.
All clinical records will be maintained as required by applicable legal and ethical standards according to the various counseling professions licensing boards, i.e. Association and National Association for Social Workers/Psychotherapists.
Emergency services are not available. In the case of an emergency, clients should dial 911, contact their Family Practitioner, or go to the Emergency Department of any hospital.
I agree to pay for all consultation and counselling/psychotherapy services provided to me at the rate of CA$210 per individual session, CA$250/session for couples therapy. The usual session is 50 minutes. I agree to pay in full at the end of each session, unless another arrangement is agreed upon. Rates for online video or telephone psychological assessment / psychological therapy sessions are the same as face to face sessions.
Fees may vary according to the time and nature of the service(s) involved (e.g. report writing will be billed at your regular appointment fee; telephone conversations in excess of 10 minutes will be billed at your regular appointment fee, in quarter hour increments; and consultation with other professionals will be billed at your regular appointment fee, in quarter hour increments) and you will be advised in advance if any changes are made to the fee. All fees charged follow the guidelines set for the psychotherapy and counselling. Generally, clients pay for their sessions at the end of each session. In this way, the account remains manageable and counselling becomes a naturally budgeted expense. Fees may be paid by cash, cheque or major credit card. Fees may be held in trust. Outstanding accounts of more than 60 days will be eligible for submission for collection.
A form of reliable payment must be established before the first session occurs. Credit card or other online payment arrangements will be made at intake or your first session.
A fee will be charged to clients who do not show or who do not cancel their appointments within 48 hours of their scheduled appointment. Late cancellations and no shows will incur a fee, which must be paid before the client receives his or her next psychological therapy session with their therapist. Orangebloom Therapy will process the no show or late cancellation payment on the day that it occurs. We reserve the right to use the client’s payment preference that was provided at intake.
Psychotherapy with Registered Social Worker services are not covered by OHIP, but are often partially or fully covered by most extended health insurance/ benefit plans. Various plans differ, so please check with yours regarding coverage and claim procedures.
Fees paid for psychotherapy services may be eligible for inclusion in your medical expense deduction on your income tax. You will be given a receipt for each payment, which you should retain for income tax or other claim purposes.
I hereby authorize Orangebloom Therapy and Counselling and its representative Lior Svetlana Model to release my information to the following entities:
I hereby give my permission and consent to Lior Svetlana Model, RSW, MSW, who is a registered social worker and a certified member of Ontario College of Social Workers, RSW #816091, to provide online and in-person psychotherapy services to me and/or my child.
I understand that psychotherapy entails both benefits and certain risks, and that there is no guarantee that psychotherapy will be successful. I understand that it is important that I mention promptly any concerns or questions I have at any time during the process of therapy.
I understand that the video conferencing technology will not be the same as an in-person session with a provider since I will not be in the same room as my provider. I also understand that, in order to have the best results for this session, I should be in a quiet, private place with limited interruptions when I start the session.
My provider agrees to inform me and obtain my consent if another person is present during the consultation, for any reason. I agree to inform my provider if there is another person present during the session.
I understand that this consent will last for the duration of the relationship with my provider, including any additional video psychological therapy sessions I may have.
I understand that I/we have the right to withdraw consent for psychotherapy services at any time.
By checking the box and printing my name/child’s name and date below, I certify:
•That I have read or had this form read and/or had this form explained to me.
•That I fully understand its terms of service including the risks and benefits of the procedure(s).
•That I have been given opportunity to ask questions and that any questions have been answered to my satisfaction.
•That I voluntarily agree to participation in a video psychological therapy session(s) with Lior Svetlana Model, MSW, RSW #816091 under the terms of service.
