Child / Teen Account Setup
All RED fields are mandatory
Child First Name
Child Last Name
Child Age
Child Birthdate
Parent/Guardian Full Name
Address
School Name
School-Grade
Do not include numbers which you do not wish to be contacted at
Phone Number
Alt Phone
Marital Status of Biological Parents
If custody is shared, we require written consent from
both parents to counsel children who are less than 12 years of age.
If separated or divorced, do you have sole legal custody of your child?
Legal Custody YesNo
SIBLINGS
1st Sibling
Age
Relationship BiologicalStep
2nd Sibling
3rd Sibling
4th Sibling
Do any of the child’s siblings have special needs or issues?
If applicable, explain here
(A credit card is required to be on file)
Contact First Name
Contact Last Name
Contact Phone
Contact Email
Credit Card Number
Name on Card
Expiry Date “01/23”
CVV
Postal Code
INFORMED CONSENT
All verification boxes must be checked
CONFIDENTIALITY: All the information gathered and recorded, for the purpose of providing continuity and quality service, is stored securely and remains confidential. The Personal Health Information Protection Act (2004), and the Professional Colleges govern our record keeping and disclosure policies. Information will be communicated or disclosed to others only with your written informed consent. Exceptions include the following legal and/or ethical obligations: • Knowledge or suspicion of child abuse or neglect • Declared intent to seriously harm oneself or a specific other • A court order or legal proceedings • Clinical supervision or consultation using first name(s) only
OFFICE TEAM: Family Matters Center office team and your insurance company may access/request information regarding your appointment dates, times and fees (for validating your insurance request or to maintain your records).
EMERGENCIES: Family Matters Centre (FMC), does not provide emergency services. In case of emergency, please call 911, your family physician, [ADULTS] COAST 1-877-825-9011, [KIDS] Help Phone 1-800-668-6868 or visit the local hospital emergency department.
INSURANCE COVERAGE: Psychotherapy services are often covered by extended health insurance plans or by Employee Assistance Programs. Please check with your insurance company, human resources, or union office to learn about the availability of insurance coverage. The processing of insurance claims, Employee Assistance Programs and/or other forms of financial reimbursement available to you is your responsibility.
FEES AND PAYMENT: The fee for an individual or couples counselling session is $155/hr + hst ($175.15) or $175.15. Family sessions are $175/hr + hst ($197.75) or $197.75. Sessions are 50 minutes in person, leaving the counsellor 10 minutes for updating notes. A credit card (VISA or MasterCard) is required to be on file and is charged up to one business day after each session. A receipt will be provided for insurance or income tax purposes. Any outstanding balance must be paid prior to additional services. Additional fees will be charged for photocopying, reports and letters written on behalf of the client, reprinting receipts, etc. Please ask to see a list of our fees, should you require services other than counselling.
CANCELLED OR MISSED SESSIONS: It is greatly appreciated if sessions are cancelled or rescheduled well in advance. A $75.00 fee may be charged for missed sessions or for those cancelled with less than 24 hours notice.
EMAIL: Email is not considered a secure and confidential way of communicating. For the protection of your privacy, please do not email information you would not be comfortable discussing in a public space.
CREDIT CARD: You hereby grant authorization to Family Matters Center Inc. to charge the credit card you provided for approved purchases. Please be assured that your credit card details are safeguarded through integration with one of the world’s leading credit card processing systems, and are not stored within our organization’s records after your account has been setup.
ONLY PRESS THE ‘SEND INFORMATION’ BUTTON ONCE. It does take up to a MINUTE Please wait until it confirms.
