Hello! Thank you for considering the Possibilities Clinic for Coaching, Psychotherapy, and/or Academic Services. We would be honoured to support you by booking the appointments you need. Before we do that, we require your acknowledgement of the following details around privacy, confidentiality, and insurance coverage. Once you click yes, you are on your way to sharing your concerns and getting an appointment booked with our exceptional coaches, therapists and tutors!

• Our online forms use SSL encryption to maintain secure transmission of medical information. Forms must be submitted online. This document will be added to your chart in our electronic medical record system and cannot be deleted. Our electronic medical record system is mandated by the Ontario government, professional regulatory organizations, and privacy laws. 
  
  
• Complete this form if you are interested in receiving Direct to Coaching, Psychotherapy, or Academic Services. If you wish to receive Assessment and Diagnostic Services from our multi-expert team please complete our standard Clinic Intake Form for children and teens or adults instead.
  
  
• Private therapists and coaches from various disciplines are available at Possibilities including Psychologists, Registered Psychotherapists, Social Workers, Occupational Therapists, Speech and Language Pathologists, Nurses, Certified Leadership Coaches and Teachers. Rates range from approximately $180 to $290 per session. Services from these providers are not covered by OHIP. Fees may be covered by private insurance plans. Please check with your insurer for potential coverage.
  
  
• Most services are delivered over secure video sessions. 
  
  
• Yes, I understand that the Possibilities Team can only respond and book an appointment for me after I have filled out and submitted this intake form.

Please begin by sharing your information with us. If you are completing this form on behalf of another individual, please share your relevant details first.

How can the clinic best reach you or your child about the appointments?

Please list a phone number where we can leave a message.

If applicable, please list current school information:

Whether in person or on secure video, we aim to provide you with professional service in a comfortable, safe, and friendly environment. The Possibilities Clinic is multidisciplinary, meaning we work in teams with professionals across various areas of expertise. A multidisciplinary approach allows us to provide highly specialized, comprehensive, and integrated assessments and treatments. This consent form applies to all the services you may access at our clinic including, but not limited to, Psychology, Psychotherapy, Psychiatry, Family Medicine, Paediatrics, Occupational Therapy, Speech-Language Pathology, Social Work, Psychometry and Education.

Collection and Sharing of Personal Information
Personal information will be collected during assessment and treatment. This information could include identifying information (e.g., name, contact information), test results, reports, progress notes, payment information, and any information collected with your permission from other health care providers. Our records are kept secure in a confidential electronic file and in accordance with legislative health privacy guidelines. Records are kept for a minimum period of 10 years or 10 years past your child’s 18th birthday if your child is a minor at the start of assessment or treatment. You have the right to obtain copies of your file or your child’s file (if under 18 years of age at time of request). All file requests are subject to an administrative fee.

Your consent allows us to share information with all experts involved in assessment and treatment within our Multidisciplinary Care Team. Your information will also be shared with our Administrative Team for booking, billing, and other administrative purposes. 

Your consent also allows us to share information with your referring physician in the community. However, if you would like us to send information, including Assessment Reports, to anyone else outside of the clinic, your written consent on a separate form, authorizing release of information, will be required. 

Assessment Specifics 
Through the use of standardized tests, measures, and interviews, we will attempt to answer the questions that have brought you to Possibilities for assessment. Once we review the information and results acquired during the assessment, a report will be written detailing findings and our interpretations and recommendations. You will have the opportunity to meet to discuss the results, interpretations, and recommendations with members of our Assessment Team. You will also receive a copy of the report.

Treatment Specifics 
The treatment process generally involves an initial intake session with the patient or, in the case of children and adolescents, with parents or legal guardians. At the end of the initial intake session, type of treatment, treatment goals, and frequency and duration of sessions can be determined. For treatment with children and adolescents, some treatments involve working with parents directly, some involve working with children and teens directly, and some involve a combination, working with all members of the family together or in separate sessions. 

Possible Risks, Discomforts, and Benefits of Assessments and Treatments
Your consent indicates that you understand the purpose of the assessment or treatment that you are seeking for yourself and/or your child or adolescent. Assessments and treatments are designed to benefit your daily functioning and support positive outcomes. In the course of an assessment or treatment, interview questions may touch on personal and private matters that could revive painful memories. Your consent implies that you recognize that clinicians and interventionists who carry out assessments and/or treatments with you, your child, or your adolescent have no intention of causing any personal discomfort, but are performing professional tasks that are typical and  reasonable for the assessment and/or treatment being pursued. For some individuals, participation in an assessment or treatment may cause temporary fatigue, physical discomfort, frustration, and/or stress. Our staff will do everything reasonable to minimize any such discomfort. 

If medications are recommended and prescribed as part of a treatment plan, verbal consent will be obtained after the risks and benefits of the medication treatment plan have been discussed, and prior to initiation of treatment.

Limits of Confidentiality
Your referring physician will receive assessment reports and treatment information as part of your circle of care. Beyond your referring physician, information contained within your clinical record cannot be released outside of the Possibilities Clinic without your written permission, except as required by law. Exceptions where information must be released include:

1. Situations where you are a danger to yourself or others
2. If there are grounds for apparent, suspected, or potential child abuse
3. If there are grounds for apparent, suspected, or potential elder abuse if living in a long-term care or retirement facility
4. If you report sexual abuse by a healthcare professional
5. If information is subpoenaed by a court
6. If your file is subject to a review process by licensed peers or a professional licensing body in accordance with Regulatory Professional Colleges
   
   

Teaching Facility Specifics
The Possibilities Clinic serves as a teaching facility for individuals in training in all professional specialties represented at our Clinic. As such, some assessment, diagnostic and treatment procedures you or your family receive may involve a medical resident, a practicum student, a graduate intern, a post-graduate clinician working towards professional licensure, or a trainee in psychometry and associated interventions. In all cases, individuals in training are working under the direction and supervision of  licensed physicians and/or allied health professionals at the clinic. Prior to any session, you will be informed of an individual’s training status and the name of their direct clinical supervisor. In cases where an individual in training is observing a clinical session or performing clinical functions, you retain the right to decline the involvement of the trainee.

Multidisciplinary Team Process
At Possibilities, we offer a unique team approach to diagnosis and treatment. For clients, multiple clinicians from different disciplines form Core Diagnostic and Treatment Teams. Gathering data, reviewing information, measuring skills, making diagnostic decisions, and formulating treatment recommendations are done by each client’s Core Team members. In addition, the Core Team consults additional clinicians at Possibilities—also from multiple disciplines—for additional data review and recommendations during Clinic Rounds before diagnostic and treatment recommendations are finalized and prioritized to support success. Clinicians on the client’s Core Team, as well as additional clinicians consulted during Clinic Rounds, all adhere to standards of confidentiality regarding client information, diagnoses, and treatments.

Our Adherence to Guidelines and Protocols
Assessments at Possibilities follow specific testing protocols, whether they are conducted in person or through secure video sessions. Guidelines for video testing were created based on recommendations from professional consultations, and education provided by licensed clinicians, researchers, and test developers experienced in the provision of video testing and knowledgeable about research supporting the effectiveness of this approach. Research guidelines from published studies on remote testing were also consulted. Measures taken in our video assessments following suggested protocols include, but are not limited to, 1) explaining to parents/guardians their role as facilitators in ways that support technological solutions while preserving the validity of child responses, 2) using shared screens to present testing stimuli, 3) when indicated, sending paper response booklets in sealed envelopes that remain unopened until the examiner indicates they are needed, and 4) having clients seal envelopes on camera after a paper protocol is completed. Our adherence to guidelines and protocols for video testing supports the validity and reliability of the data we collect across assessment sessions. Additional testing guidelines were followed based on Possibilities Clinic Multidisciplinary Team Assessment protocols, specifications outlined in standardized test manuals, and in accordance with professional training in test administration.

 Declaration and Consent

I have read this consent form, understand its contents, and agree to its terms for assessment and/or treatment. Furthermore:

1. I understand that consent is an ongoing process and that I can ask to revisit this continued consent at any point in time in the assessment or treatment sessions.
2. I understand that I have the right to stop the assessment and/or treatment process at any time.
3. I understand that if I am unable to relay, or do not  provide relevant background and health information, this omission may affect the completeness and accuracy of assessment conclusions and any diagnoses made, as well as the effectiveness and safety of treatment. 
4. I have read the Assessment Checklist and understand what I need to provide to ensure accurate testing results.

Please read this document carefully. It will help you make the most of your appointment and help us provide you with a successful outcome. Once you’ve read through this document, please sign and submit.

Is a video visit just like an in-office one?
Yes! Like our in-person assessment, the video option provides live access to members of our Multidisciplinary Team who specialize in different fields like psychology, medicine, speech-language pathology and social work. Most of our diagnostic tests and treatments can be done over video. Our experience has been that video appointments are convenient and replicate the in-person experience. At times, however, the clinician may determine that an in-person visit is needed and will discuss this possibility with you.

Is my video appointment secure?
We use secure and encrypted platforms that are licensed for medical settings.

How do I access my video appointment?
If you’ve tested your connection and downloaded the applications for your phone, tablet, or computer, all you will need to do is click on the appointment link that was sent to you. We recommend that you log on through the link 5 minutes before your scheduled appointment. You’ll be automatically connected and placed in a virtual waiting room. Your clinician will admit you into the consulting room at your designated appointment time.

What do I need to do to prepare for my secure video appointment?
We recommend you test your smartphone, tablet or computer well ​before​ your appointment time. There is nothing more frustrating than having to use the first part of your valuable appointment time dealing with technical issues! Our appointments are scheduled in exact time slots, and your appointment time cannot be extended.

What locations do you suggest for the video appointment?
Confidentiality is our utmost concern, and your session needs to be in a private and quiet space to protect you and your family’s privacy. Please ensure that your session takes place in a comfortable setting, with no interruptions or distractions. Video sessions must remain secure—so they cannot proceed if you are in a public space where conversations can be overheard.

Can I see you from anywhere in Ontario?
Yes! Our clinicians are licensed to practice across Ontario and you can be anywhere from Windsor to North Bay. If you are not a permanent resident of Ontario—you can still see us—but you must conduct your session within Ontario, and you may not be eligible for OHIP coverage. 

What if I’m a resident of Ontario but travelling or studying elsewhere in the world?
Our clinicians are only licensed to serve people within Ontario. Even if you are an Ontario resident, we cannot see you while you are traveling abroad or in other provinces. You must conduct your video session while being physically present in Ontario. We are unable to verify your physical location during our video sessions; by signing below you are consenting to this condition and agreeing to attending video sessions only while physically present in Ontario.

Do you have any suggestions for making the most of my video appointment?
If you’re joining as a couple or family, we recommend that you use a tablet or computer (PC or Mac) rather than a smartphone. A smartphone camera doesn’t have a wide enough lens for a clinician to see more than one person at a time. We want to see everybody! And the microphone and speaker on a smartphone are often not strong enough to pick up voices far from the phone. We want to hear from everybody! And we want you to hear us, too!

If you ​are​ using a smartphone or tablet, please place it on a stable platform in front of you rather than holding it in your hand. Movement from the camera during the session can be distracting, and your session will feel less like an in-person visit.

What if I miss my appointment, or I’m late for the session?
Video appointments are scheduled just like in-person appointments. Your clinician has set your appointment time aside for you. There are clients booked before you and after you—just like in-person appointments—so your appointment time on video cannot be extended if you are late. If you miss your appointment, or cancel with fewer than 72 hours notice (based on business days), you will be charged a cancellation fee.

What if I’ve changed my phone number or email?
If you have changed your phone number or email address, you are responsible for letting us know. We must protect your privacy, so we can only send your appointment information to the contact number or email you’ve given us. If we hear about a change from you, we’ll change your contact information in our file.

 Declaration and Consent

I have read this consent form, understand its contents, and agree to its terms for my video appointments.

Please Note:  

Our online forms use SSL encryption to maintain secure transmission of medical information. Forms must be submitted online.

Thank you for choosing the Possibilities Clinic. We continue to evolve in our processes to help support how we offer and deliver our comprehensive, multidisciplinary services for you. To reserve all of your appointments in advance, we now require a credit card to be kept on file. This new system improves convenience for our clients. It ensures that appointments made for you or your family are reserved well in advance, and that your assessment and treatment is never interrupted due to a missed or late payment.

Please find our guidelines for payment outlined and clarified below.

Payment Method

• The Possibilities Clinic requires a credit card to reserve all Assessment and Treatment appointments. Assessment and Treatment costs vary depending on the service.
• Credit Card information is obtained over the phone and is securely saved in Intuit Quickbooks Online. We do not keep your credit card information in your medical record. 
• If we are unable to process your credit card, future appointments will not occur until all outstanding balances are paid.

OHIP and Potential Insurance Coverage

• Appointments involving a physician are covered by OHIP when a valid Ontario health card is presented. Without a valid Ontario health card, you will be billed for the physician appointments. 
• You will be invoiced for other services you request that are not covered by OHIP, such as Record Requests, completion of Accessibility and Disability Forms, and Multidisciplinary Team Assessments and Treatments that involve allied health and education professionals (e.g., nurses, psychologists, psychotherapists, psychometrists, social workers, occupational therapists, speech-language pathologists, teachers and academic instructors) 
• Many fees may be covered by private insurance plans. Please check with your insurance provider to determine if you have coverage for specific professionals prior to booking your appointments. Possibilities Clinic is not accountable should your insurer decline your claim. Estimate quotes can be provided upon request prior to booking appointments.

Payment Processing and Confirmation

• Confirmation of all payments will be emailed to you via Intuit Quickbooks Online. Receipts can be downloaded from the email. Please keep a record of your receipts.
• All Assessment, Treatment and Service payments will be processed on the date of your appointment or service provided, as listed on your invoice, once your appointment has ended/service is completed or on the next business day using the credit card information you have provided.

Cancellation Process

• To avoid being charged for appointments you do not attend, we require advance notice of at least 3 business days
• You will be invoiced the session fee for missed appointments, late cancellations, or late rescheduling of appointments made with fewer than 3 business days’ notice. Your credit card will be processed on the next business day.

I have read the Payment Policy and guidelines and agree to the terms.

Please be aware that all children under the age of 18 years require parental/guardian consent to access services at our clinic.  

Both parents' signatures are required, including situations where parents are separated or divorced and there is joint custody or no formal custodial arrangement.  

Each parent may sign separate custody consent forms. However both parents' signatures are required before services can be provided. Unsigned forms will not be accepted.

If both parents/guardians are unable to sign this Custody Consent form, please refer second parent/guardian to our website, possibilitiesclinic.com, under All Forms > Consent Forms > Custody Consent form.  

 Declaration and Consent

I/We, being the custodial parent(s)/guardian(s) of the above named child, consent to the assessment and/or treatment services of said child at the Possibilities Clinic.

Please note, in order to share information between the Possibilities Clinic and anyone other than the patient (e.g. healthcare provider or a parent/guardian) we require this Consent to Share Information form to be completed by the patient, 18 years and older, or the parent/guardian for children 17 years and younger.

I consent to release information for the above-named patient, between the Possibilities Clinic and the individual/institution indicated below, for the purposes of sharing information.

Thank you for taking the time to complete this form. Please follow the following next steps:

 

1. After clicking on the Review Button below, you will see a Print/Save button.

2. Please print or save a copy of this document.

3. Once printed or saved, you must then Submit your form.

4. If you have any technical issues, please call our office at 833-482-5558.

 

We look forward to supporting you through your important next steps. Our Care Team will contact you shortly to share details about your appointment options.

Possibilities Clinic Team