Dr. Roselynne Webbo
Psychological Services
rwebbo@yahoo.com
Tel 902 394 0028
Consent to Psychotherapy
At Dr Roselynne Webbo Psychological Services (RWPS) the model used for therapy is generally,
but not always, short-term, lasting between 6 -20 sessions, each 50 minutes. Therapy may occur
once a week or otherwise, as the therapist and client collaboratively agree is required.
The purpose of therapy is to improve your emotional and psychological health. Therapy methods will
vary depending on the problem and treatment goals you wish to address. Your therapist will discuss with
you treatment suggestions, therapy methods and techniques, and discuss the benefits and possible risks
of treatment, the probability of success, the prognosis without the treatment, and possible alternative
approaches. You should be aware that you have the right to a second opinion and to terminate therapy as you see fit.
We will discuss the fee and payment arrangements with you as early as is reasonably possible, as well
as the cancellation policy, which requires 24-hour notice for missed appointments. Without such notice,
you may be charged for the appointment that was held for you.
You are informed that information shared with your therapist will not be shared with others without your express written consent. Client files are kept in a secured filing cabinet or on a secured server and will be stored for a minimum of 10 years following the date of your last contact with (RWPS)
However, there are the following limits to confidentiality:
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In situations where there is a court order, the practitioner is legally required to submit the requested information or documents.
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In situations where the client intends to cause serious physical harm to him/her/themselves or to another person, steps must be taken to offset the consequences of such action.
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The Regulated Health Professions Act makes it mandatory to file a report when the practitioner has reasonable grounds to believe that a member of the same or different college has sexually abused a client.
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The Child and Family Services Act states that when a practitioner has reasonable grounds to suspect that a child has, or may have suffered abuse (including physical, sexual, emotional abuse and neglect) the practitioner shall report the suspicion and the information on which it is based to child welfare.
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Mandatory reporting is required if there is reasonable grounds to suspect the abuse or neglect of residents of long-term care or retirement homes.
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If the Psychologists Board conducts an audit of the practice files, for quality assurance purposes.
Virtual Sessions
All sessions in Ontario are currently offered virtually and PEI offers both virtual and in-person session. We prefer to conduct sessions through online video conferencing since this allows you and your therapist to see each other, however, phone sessions are also possible if you do not have access to a computer or internet. The clinic uses the secure Zoom platform which is compliant with privacy requirements.
Technology Limitations
While RWP will make every reasonable effort to implement technical security measures to reduce the
risk of a confidentiality breach on its end, I recognize and accept the risk that no internet-based
communication can be guaranteed to be 100% secure or confidential, and that risks such as internet
participation being discovered by others and the possibility of hackers may still occur. I accept that I may
be required to provide proof of my identity or other identifiers in order for RWPS to ensure that my
information and service sessions are adequately protected. also understand and accept that technical
difficulties or complications may occur at any stage and part of my online therapy sessions. Such may
include but are not limited to login difficulties, time delays/lags, equipment failure, slow internet speed,
and others. In the event that any of my online therapy session is disrupted, my therapist will attempt to
re-establish our online connection. Should the technical difficulties persist, making it not possible or
feasible to continue our online session, my therapist will make efforts to continue our session through
other means such as over the telephone or they may have Insight reschedule another online or phone
session for me.
Client Responsibilities for Online Sessions
In order to minimize difficulties or interruptions with my online therapy sessions, I will:
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Use high-speed password protected Internet connection or secured, encrypted wi-fi connection. I will download and use Google Chrome web browser when and where needed to facilitate my online therapy sessions.
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Use a computer or laptop on which appropriate antivirus/firewall and security software (e.g. paid versions of Bitdefender, McAfee, Norton, Kaspersky, etc.) has been installed and activated,
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Ensure that the audio, mic, and visual tools on my computer or laptop are fully functioning,
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Plan ahead to minimize distractions (e.g. use a quiet room that I can be uninterrupted, not answering calls or text while in session, use headphones to increase privacy if necessary),
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Log-on five minutes early to ensure that the online platform is functioning
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Close other programs on my computer prior to the start of my session,
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NOT have any additional individual(s) other than myself be present in my online therapy sessions without prior approval from my therapist. Should their presence be allowed, I will ensure that they read, understand, and agree to the terms and conditions in this Consent for Treatment, and
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NOT record (audio, video, or any other form) or share any portion of my online therapy session(s) with any party without prior written approval from RWPS.
Payment
The fee for individual therapy will be: $275 per 50-minute session, and $ 415 for couple therapy (75
minutes - 90min). The full session fee will be charged for missed appointments that were not cancelled
within 24 hours.
Payment is accepted in the form of cash, or credit card - including Visa, MasterCard and e transfer. A
valid credit card is needed on file regardless of how you plan to pay. Your consent below represents pre-
authorization to use your credit card to charge for fees and services.
E-transfers can be sent to rwebbo@yahoo.com
I understand that all payment is due at the conclusion of the appointment. I consent to RWPS using my
credit card information unless different form of payment (e-transfer or cash) is being used. I am aware that I am responsible for timely payment regardless of payment method and if this payment is not received in the same day of the appointment, Dr. Roselynne Webbo Psychological services will charge my credit card instead for the owing fees.
Credit Card Authorization
I authorize Dr. Roselynne Webbo Psychological Services to charge my credit card for agreed-upon services and purchases, including fees for no-show or late cancellations (within 24 hours). I understand that I will receive a separate call from Dr. Roselynne Webbo Psychological Services to collect my card details.
Cancellation Policy
Your appointment time is reserved just for you. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged 100% of the session fee.
I am aware of the Cancellation Policy.
Lastly, signing this form indicates that you have had a chance to ask questions and obtain understandable answers, that you have received and understood the above cited information and that
your consent to begin treatment with RWPS is voluntary.
Thank you for submitting!