Associate Services Consent Form
This document serves to clarify that psychological services will be provided to me by an associate of Frontline
Resilience, with the supervision of Dr. Lori K. Gray, C. Psych., who is a Clinical, Forensic, and Rehabilitation
Psychologist and member in good standing with the College of Psychologists of Ontario (CPO). The name and
credentials of the associate have been provided to me separate from this letter. Dr. Gray is responsible for the
oversight of psychological services provided to me, with the associate having the training and experience to
deliver the psychological services within this supervisory relationship. The associate may not reassign the
provision of your psychological services to another provider, but may provide referrals to you as needed.
Shared Access to Information:In light of the supervisory relationship noted above, both Dr. Gray and the associate will have access to my file information and all information about the psychological services provided.
Contact information: To reach Dr. Gray directly, please contact the main office via phone (1-833-376-6856) or fax (1-833-376-6855). Meetings can be arranged at the request of you, the associate, and/or Dr. Gray.
Controlled Act of Communicating a Diagnosis: Only members of the CPO may perform the controlled acts with which they are legally authorized to perform, except as specified by the CPO Standards of Professional Conduct. As a result, only Dr. Gray may perform the controlled act of communication of a diagnosis, either in person or through ‘real time’ communication such as by telephone, teleconferencing or videoconferencing.
Requests for Documentation: Documentation requests must be sent to Dr. Gray, who shall co-sign all psychological reports and formal correspondence related to psychological services provided by the associate.
Billing and Receipts: Billing and receipts will be in the name of Dr. Gray (Lori K Gray Psychology Professional Corporation, Frontline Resilience) and will identify the associate’s name, degrees, and professional designations.
Coverage for Psychological Services: It is your responsibility to verify with your extended health benefits company, insurance company, and/or third party payor whether your policy covers psychological services provided through a supervised practice model, and whether your policy requires specific coverage and claim procedures (e.g., whether a referral from my physician is required, details required on receipts, etc.).
I have read the information above and agree to proceed with psychological services provided by the associate
with the supervision of Dr. Gray.
