Prior to attending your first appointment, it is helpful if you can copy and paste the following form into your word processing program, complete the form bring the completed form with you.
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Counselling & Mediation Services
Leland Clipperton, H.S.C.
_________________________________________________________________________________________________________________________________________________________
Phone: (905) 510-9117
(705) 443-8290
Email: leland@CounsellingandMediation.com
Therapy Contract
Name: __________________________________________
Address: ______________________________________
Postal Code: ______________
Phone No.: [Home] _________________
[Business] ______________
Email Address: _______________________________
Date of Birth: ________________ Referred by: ____________________
You have made the first step to your ongoing change process. This has, no doubt, been a challenging decision to make. Therapy can be hard work. Much of the process involves sharing your personal thoughts and feelings.
Your commitment to undertake therapy at this time in your life will be best served if you give this time the greatest value you can. There is a direct relationship between successful outcome of therapy and how strong your belief in the process is. In other words, the more value and positive belief you place on your therapy, the greater your success will be.
Therapy can often feel difficult and you will likely have times when you will feel that something or someone seems to take priority over your scheduled sessions. This may also be an ideal opportunity for your own personal growth. It is often more valuable to work through this conflict you may experience while in a supportive environment.
Most clients whom attend regular weekly sessions find it easier to book the same time and day. ie. Wednesdays at 10:00. Sessions are 55 minutes in duration. Regular and timely attendance at all sessions is expected. Clients are responsible for payment of all sessions.
Fees are $100.00 per session for individual counselling, $130 for couples counselling, $40.00 for each group session and $160.00 for mediation. Payment in cash is required at each session. Fees are not covered by O.H.I.P. Please check with your individual insurance company for possible extended health plan coverage. Employee assistance program coverage may also be available.
I have read and understand the above.
Signed: __________________________
Date: ___________________________
