Dr. Destun & Associates

Psychologists in Private Practice

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Psychologists in Private Practice

November 2017 Not Currently Accepting Couples ; 10-Week Waiting List for Individual Therapy

Our Treatment Contract

Welcome to our practice. Please take some time to read the information in this contract carefully, as it contains important information about our professional services and business policies. Please bring any concerns or questions to our attention when we meet so that we can clarify and discuss any issues prior to your signing this contract.

Fees

Psychological services are not covered by OHIP. The fees charged in this office follow the guidelines set by the Ontario Psychological Association. The fee for ongoing psychotherapy is $190 per 50 minute session for individual psychotherapy and $230 per 60 minute session for couple therapy. Generally, clients pay at the end of each visit. Payment is made by cash or cheque. If you have insurance that reimburses you for psychotherapy expenses, you will be provided with receipts and other necessary supporting documentation for submission to your insurance company. Please be advised that our office reserves the right to pursue unpaid accounts through the use of a collections agency if need be.

Cancellations

Once an appointment is made, that time is reserved for you. Accordingly, you must give at least 24 hours notice to cancel an appointment, otherwise you assume full responsibility for the full fee of the missed session. Third party payers will not pay for missed sessions; therefore, if your sessions are being paid for by a third party (e.g., RCMP, Victim Services, Veteran’s Affairs) and you miss an appointment without giving 24 hours notice, you will be required to pay for the missed session on your own. Your therapist may require payment for the missed session before scheduling another session with you.

Emergencies

As we do not have support staff in our practice, you will often get the answering machine when you call. Voicemails are checked at least daily, Monday through Friday. If you feel that you need to be seen immediately or if you are calling outside of business hours, you may wish to consider going to your nearest Emergency Department.

Terminating Therapy

You are free to leave therapy at any time. If either you or I feel that I am not the best person to help you with your particular difficulty, our office will gladly provide you with the names of other qualified local professionals.

There are also some circumstances under which I might choose to terminate therapy. Any threats (verbal or physical) directed toward myself or the office will result in termination of the therapy. A pattern or missed or cancelled appointments may result in termination of the therapy. We also reserve the right to terminate therapy when there is an outstanding account that is not being addressed.

Your signature below indicates that you have reviewed the above, and consent to psychological assessment/treatment.

Signature of Client
Date
Signature of Witness
Date

PLEASE WAIT AND SIGN THIS IN SESSION