Client Consent, Assessment & Confidentiality Form

Please fill out the following form.

Client Information

Insurance Policy Info

If you plan to use your insurance benefits please fill out the information below:

Client Consent & Confidentiality

UPI Health believes in the privacy and confidentiality of your personal information and it is one of our highest priorities. We recognize that privacy is an important issue and that you trust us to respect individual privacy and ensure the confidentiality of collected information. Our therapists are fully bonded and bound to the principles of confidentiality and professional legal and ethical requirements. Access to and use of personal information is limited to you only and where you would direct your clinical notes. Be aware that under Canadian law our therapist’s clinical files can be court-ordered for viewing by a judge.

UPI Health’s Therapists follow the confidentiality rules as outlined by the provincial jurisdiction and requirements within the province they reside.

By signing this declaration you acknowledge the following:

1) I understand that UPI Health and/or its Therapists will not divulge confidential information to any person/employer without my informed, voluntary and written consent.  

2) I understand there are exceptions to legal confidentiality and professional ethics.

Exceptions include but are not limited to:       

• Files subpoenaed by a court of law

• Disclosed or suspected child abuse/neglect

• Perceived threats of violence/risk to oneself or to others (i.e. threatens suicide; threatening to injure others)

• Employee’s occupation is considered to be safety sensitive and the employee is imposing an imminent risk of harm to self or to others by carrying out their job duties. (i.e. employee who is intoxicated when operating heavy machinery) 

  
  

3) If I have any concerns related to my care or company policies, I understand I can contact the College of Registered Psychotherapists or the governing body for Psychotherapists in the province in which the therapist resides.

I understand and consent to all of the above conditions and I hereby consent to participate in this therapeutic process with UPI Health Therapists.

Cancellation Policy

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the practitioner’s day that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged a cancellation fee.

Client Intake Information

The info below is passed onto your therapist so they can create a specialized plan for you.

Consent to Treatment

I understand that counselling is a voluntary process and I may choose to discontinue at any time. I consent to participate in counselling services provided by this agency.