Practice Information, Fees & Informed Consent

Purpose of This Form

Before you begin therapy, it is important to fill out a client intake and informed consent form. This form has two purposes:

• To collect your general personal and contact information, including how you prefer to be contacted while you are in therapy.
• To outline the important aspects of your psychotherapy agreement with Jan - including policies, payment for services, and confidentiality - so that you can give informed consent.

Please carefully read through all sections, then fill out and sign the form to complete your intake process.

What You Can Expect From Your Therapy

As a registered psychotherapist, Jan Tkachuk is a member of the College of Registered Psychotherapists of Ontario (CRPO) and adheres to the code of conduct and standards set out by this regulatory body.

Part of these standards involve being PHIPA compliant - meaning Jan follows Ontario's privacy laws about personal health information to keep your health records safe, private, and properly managed. All bookings, direct messaging, professional letters, notes, forms, uploads, recordings, and any other information shared within this Owl practice portal are protected to these privacy standards.

Please note: if you text or email outside of this platform, that information may not be secure. I encourage you to send sensitive information through this secure platform.

Confidentiality Understanding

All information shared with Jan will be kept confidential, with the following exceptions:

1. If subpoenaed to provide documentation or to testify in court, Jan is required by law to do so.
2. If a client reports current child abuse, Jan is required by law to report this information to the Children's Aid Society.
3. If a client presents an imminent danger to themselves or to others, Jan is required to communicate this to the police to help ensure the client's safety and/or the safety of others.

Session Length

Sessions are at least 1 hour in length. You may want to book a longer session in advance or, if available, request extra time at the end of a session. After the initial hour, extra session time is booked and billed in 15-minute increments.

There is no standard, required, or optimal time between sessions. The number, length, and frequency of your sessions will vary according to your needs, your schedule, and Jan's availability.

Fees and Payment for Services

The standard fee is the same whether your sessions are individual or couple work. Billing is based on the actual time used in session. Group work is billed at a flat fee.

Service	Fee
Standard session (1 hour)	$180
Each additional 15 minutes	$45

Payment of the fee is due, in full, at the time of your session. Payment options include: Cash, E-transfer, Cheque.

Psychotherapy rates generally increase slightly every two to three years. Should a rate change happen while you are actively in therapy, you'll be given advance notice through the portal messaging. You'll be given receipts for reimbursement purposes, and it is your responsibility to claim your benefits.

NIHB benefits and disability claims which must be billed directly to the third-party payor will be processed by Jan.

Cancellation & Missed-Session Policy

Your appointment time is reserved specifically for you; therefore, Jan requires at least 24 hours notice of any change or cancellation. You will be charged the full fee for any session you miss or for which you do not provide at least 24 hours notice to cancel or change.

You are welcome to rebook, cancel or change appointments directly in the portal and I encourage you to use the portal reminder system if it helps you keep track of your sessions.

To avoid paying for a missed session or a late cancellation, please try to anticipate weather, travel, internet connection, and other circumstances that could affect your ability to attend or to give sufficient notice.