Student Service Request
Interested in arranging an intake with our student clinician Bruce? Let’s get in touch.
Complete the following form and Bruce will follow up at their earliest opportunity to make arrangements.
Fee Policy: Bruce’s initial 80-minute individual intake session is $80 and subsequent individual sessions are based on a sliding scale of $80 - $130 per 50-minute session and $120 - $195 for 80-minute sessions. Bruce’s initial 80-minute couples intake session is $160 and subsequent individual sessions are based on a sliding scale of $110 - $165 per 50-minute session and $160 - $248 for 80-minute sessions.
At the conclusion of the initial intake session, as you know your own financial status, Bruce will ask you to identify the amount that is commensurable with your financial abilities.
Payment Policy: All session payments for sliding scale appointments are by eTransfer only and sent at the same time you schedule each appointment. Please send all eTransfers to firstname.lastname@example.org noting Bruce’s name in addition to your session date and time. If payment is not received within 24 hours of scheduling, the appointment will be cancelled. Please contact our Clinic Director, Adam Terpstra (email@example.com), with any questions.
All session payments for full rate appointments are by cash, cheque, credit card, debit, or eTransfer, and made at the end of session. If paying by cheque, please make payable to Adam Terpstra. If paying by eTransfer, email to firstname.lastname@example.org noting Bruce’s name in addition to the session date in the eTransfer notes.
Accounts Past-Due: Accounts that are overdue (i.e., past 30 days due) will be charged interest at a rate of 3% per month (42.58% per annum), will be sent to collections after 45 days of non-payment, and non-payment of services will result in the discontinuation of services.
Cancellation Policy: When you book a session, your clinician reserves their time for you. In the event you will be unable to keep an appointment, please notify your clinician at least 24 hours in advance, so that someone else may utilize this time. Similarly, when your clinician is unable to keep an appointment with you, they will give you more than 24-hour notice and rebook to another date and time.
In the case whereby you are unable to provide 24-hour cancellation notice, unless for emergency reasons (e.g., medical or family emergencies), you will be charged the fee for your session and payment will be required at your next scheduled session.
Note: Employee Assistance Programs and other insurance-based programs will not reimburse you, the client, for missed appointment costs. Should you cancel three (3) or more appointments without 24 hours’ notice, your service will be discontinued until you are able to commit to your clinical work.
Limits of Confidentiality: Clinicians cannot disclose or release any information about you or your file to any third parties unless they receive signed authorization in writing by the client permitting them to do so. However, in some cases disclosure is required or allowed by law as outlined below. Clinical communications are confidential, but the following limitations and exceptions exist: (a) Your clinician has reasonable suspicion that you are a danger to yourself or someone else; (b) you disclose abuse, neglect, or exploitation of a child under the age of 16; (c) your clinician is ordered by a court to disclose information; (d) you involve your clinician in a lawsuit; or (e) your clinician is otherwise required by law to release information.
- All sessions are audio and / or video recorded for training purposes, viewed by the student and their supervisor, and destroyed after they are no longer needed for supervisory / training purposes with the presiding student clinician;
- Clinical sessions are typically during weekday hours (9:30am – 6:30pm);
- Clinical services are intended for personal issues; and
- After the initial 80-minute intake session, your file will be discussed with the student’s supervisor whereby a treatment plan will be discussed.
Things We Cannot Assist With:
The student clinician cannot assist with issues involving litigation, patients presenting with potential or officially diagnosed conditions (e.g., borderline personality disorder, bipolar personality disorder, schizophrenic patients, etc.), or patients who are actively suicidal or that have made recent suicidal attempts.