Psychological Services Information Form
Thank you for the opportunity to work together towards your goals. The following sections provide
additional information about psychological services provided by this office. Should you have any
questions or concerns, please discuss them with us before signing the form.
Limits of Services and Assumption of Risks:
Psychological services (e.g., assessment, education, early intervention, therapy) can carry both
benefits and risks. Psychological services have the following potential benefits:
- Help you to gain a better understanding of yourself
- Help to decrease symptoms and improve quality of life
- Provide you with techniques that help you better manage your symptoms
- Provide you with techniques that help you better cope with your situation
- Provide a supportive and confidential environment in which to explore your struggles
While these are common benefits, these outcomes cannot be guaranteed. It is also possible that
psychological services can bring up uncomfortable or unpleasant thoughts, feelings, and symptoms.
We encourage proactive, open communication. Should you have any questions, concerns, and/or
adverse reactions, please bring them to the attention of Dr. Gray at your earliest opportunity.
It is customary practice that psychological services appointments conclude 10 minutes before the
scheduled end time to allow for notes, documentation, and transition. For example, a one hour session
scheduled for 9:00am concludes at 9:50am.
Respect for the privacy of clients attending this office is of the utmost importance to us. Accordingly,
we ask that you kindly arrive no more than 5 minutes before your scheduled appointment.
Psychological services are scheduled by appointment only. Should you need an appointment more
urgently, please indicate the urgency and reason for your request and we will attempt to accommodate
your request. Psychological services provided at our office are not suitable for emergencies. You are
to call 9-1-1 in the event of an imminent threat to yourself or someone else and are to proceed to your
local emergency department in the event of a mental health emergency. The Canadian Mental Health
Association, Simcoe County Branch - Barrie offers a 24 hour crisis line and mobile crisis service
(https://www.connexontario.ca/Directory/Program/20058) can be reached by calling 705-728-5044 or
toll-free at 1-888-893-8333.
If you are unable to attend an appointment, please provide at least 48 hours notice to reschedule or
cancel your appointment. Appointments rescheduled or cancelled with less than 48 hours notice will
be billed the full session fee. Please note that since most third party payors do not cover the cost of
rescheduled or cancelled appointments, the cost will likely be billed directly to you.
Tardiness of more than 10 minutes after your scheduled appointment time will result in cancellation of
your appointment and the cancellation fee noted above.
Announcement of unexpected office closers will be made available on the main voicemail greeting.
Fee for Services:
Services are billed in accordance for the recommended rate of the Ontario Psychological Association, which is a set fee per 50-minute increment (i.e., hourly rate). The hourly rate for the calendar year in which you commenced services was provided to you via email. Fees are adjusted each calendar year.
Methods of Payment:
Frontline Resilience accepts the following payment methods:
- Direct billing to WSIB for services pre-authorized by the WSIB. A minimum of 48 hours in advance of your appointment, we will need to have received your WSIB claim number, WSIB memo (authorization) number, and details of the specific services authorized.
- Direct billing to Greenshield, when Greenshield is the primary benefits providers. A minimum of 48 hours in advance of your appointment, we will need to have received your copy of the front and back of your Greenshield card as well as a copy your physician’s script prescribing psychological services.
- etransfer to firstname.lastname@example.org received a minimum of 24 hours in advance of your appointment. A password is not required, as auto deposit is enabled. Frontline Resilience provide a receipt, forwarded to you via email.
We do not accept other payment methods, including but not limited to cash, cheque, credit, or debit.
Payment is due at the time of service. Payment methods that bounce due to non-sufficient funds
(NSF) will be charged a $25.00 service fee. Accounts that remain outstanding beyond 30 days will
incur interest calculated at the rate of 2% monthly and may be turned over to a collection service.
Termination of Services:
You may choose to terminate psychological services at any time, in which case you are welcome to
request additional referral options. Similarly, the service provider reserves the right to suspend tor
terminate services, in which case additional referral options will be offered to you.
Facility Dog and Service Dogs:
Frontline Resilience utilizes a facility dog, which is a Great Dane. Should you have any concerns,
please contact our office at least 48 hours in advance of your appointment to discuss your concerns.
In the event that you utilize a service dog, we ask that you kindly inform our office and provide the
required paperwork at least 48 hours in advance of your appointment. Emotional support animals,
companion animals, and pets are not permitted in our premises.