Consent Form

This consent form is to document that I/we give permission and consent to Yona Reznick, to provide art therapy services to myself or my child.

Step 1 of 3

Client's Name *

Email *

Date of Birth *//

Phone *

Occupation *

Emergency Contact *

Relationship to Client *

Emergency Contact Phone Number *

Name of Parent or Guardian (if client is under 16 years of age)

1. Confidentiality *

I understand

I provide individual art therapy to adolescents/children and ensure the parent/caregiver is involved in the process through consultation. At times, the parent/caregiver may be invited to participate in the sessions. However, to ensure a child’s privacy (essential in securing and maintaining the trusting relationship between the therapist and client), we will not provide detailed information to the parent/caregiver regarding what the child shared unless the child provides consent. Instead, general themes, ideas and recommendations will be provided as well as support and encouragement.

(b) *

I understand

Confidentiality is respected at all times and no information will be released to a third party without informed consent, with the following exceptions: if a client is considered to be an imminent threat to her or his physical safety or to the safety of others; if there is suspicion of child abuse or neglect, the appropriate child welfare authorities will be notified; if a client has been sexually abused by another member of the same or a different regulated health profession; if a court orders disclosure of records.

2. Benefits and Risks *

I understand

Art therapy for children/adolescents can have benefits and risks. Responses to therapy will vary from one individual to another, however, since therapy often involves exploring unpleasant aspects of one’s life, your child may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Working through difficult emotions can sometimes lead to an increase in difficult behaviors before the child/adolescent can utilize new skills or fully integrate their experiences. On the other hand, art therapy has been shown to have benefits for individuals who participate in it. Therapy can lead to better relationships, solutions to specific problems, significant reductions of negative emotions, and an increased sense of self and self-worth. Children/adolescents are unique and holistic beings that require time and assistance to grow, discover and develop to their fullest potential.

3. Online Psychotherapy *

I understand

Due to the Covid-19 pandemic, online therapy using Zoom is currently the primary method of providing art therapy. If preferable, I am available for in-person art therapy sessions at KidCrew Medical Clinic. It is very important to take responsibility for your privacy. Make sure that you and your phone or computer are in a quiet space. Also, consider a good time when there will be few interruptions.

(3b) *

I understand

You will receive a link from your therapist once you book an appointment. At the time of your session, click on the link in the email to join the Zoom session. Expect your therapist to contact you prior to the appointment if there is a problem with the computer or internet connection. If you haven’t heard from your therapist and your therapist is not there at the time of the meeting, please wait for 5 to 7 minutes before leaving the meeting. Your therapist may be working to resolve technical difficulties. If your therapist is not there after 10 minutes, you can expect a phone call from your therapist to discuss rebooking for another time. Please contact your therapist via email if you experience technical problems.

4. Record Keeping *

I understand

We require by law to maintain records of each visit and will be confidentially maintained for 10 years following termination as per the laws.

5. Scheduling, Cancellations and Missed Appointments *

I understand

One clinical hour equals 50 minutes of session time. The remaining 10 minutes of each hour are dedicated to writing client notes. Please ensure that you arrive on time for your session. Your 50-minute session begins at the scheduled time. Session times will not be extended to accommodate late arrivals. Cancellations must be received 24 hours prior to the scheduled appointment. If 24 hours of notice is not given, please contact the therapist to discuss options.

6. Fees and Payment *

I understand

Please note that my sessions are $125 plus HST. All payments are collected at the time of service. KidCrew Administration Team will send you an invoice once the service is provided and payments must be made by VISA, check, cash or email transfer. Fees may vary according to the time and nature of the service(s) involved (e.g. telephone conversations in excess of 15 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. A surcharge of $25.00 will apply to all N.S.F. cheques. A late fee or 2% per month will be added if payment is not received after 30 days of the date of service. Outstanding accounts of more than 30 days will be eligible for submission for collection.

Consent Form

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