Letter Agreement For Provision Of Counselling Services

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LETTER AGREEMENT FOR PROVISION OF COUNSELLING SERVICES between:
____________________________________ (the “Client”) and ____________________________________ (the “Counsellor”)
The Client agrees:
1. to provide your Counsellor with 24 hours’ prior notice if canceling an appointment. Your prompt cancellation will
permit someone else to use your time slot and thus reduce the waiting period for them. Your failure to provide 24
hours’ prior notice will result in a late cancellation fee of $40.00 being charged to you personally;
2. to not subpoena the Counsellor or the Counsellor’s records for any legal or court report or any court appearance,
including any industrial relations dispute;
3. to pay the Counsellor’s fees before each session by cash, cheque, VISA, MasterCard or Debit, unless you are covered
by an EFAP. In case of payment rejection by your EFAP, you are responsible for paying the Counsellor’s fees. If you
are requesting coverage through an insurance policy, you are responsible for paying the fee and submitting your
claim personally. It is the Client’s responsibility to ensure your Counsellor meets the criteria for your insurance
policy. Neither the Counsellor nor Personnel Performance Consultants Inc. (PPC) is responsible for denied claims. In
instances of inactivity on unpaid accounts, the account will be turned over to a collection agency for payment.
The Counsellor agrees:
1. to provide counselling assistance based upon the Client’s goals;
2. to maintain the confidentiality of the Client, unless:
a) you may be a danger to yourself or others, or there is a reasonable suspicion of child abuse or neglect. You
recognize in such circumstances that I have a legal and ethical responsibility to my professional association to
notify the proper authorities;
b) it is appropriate to consult with a professional colleague to improve the quality of my service to you; the
information shared with this professional colleague will be kept anonymous and is restricted to the information
necessary to aide in meeting your desired goals and to assist me in providing adequate service. This colleague will
also be held to the rules of confidentiality.
c) you initiate a legal action whereupon I may use information from my records to defend myself.
By signing this Letter Agreement, you confirm that you have read and understand the terms set out above and that you
agree to these terms. You also agree that your Counsellor is an independent contractor and is providing services to you
directly and personally. You also agree that this contract for the provision of counselling services is between you and the
Counsellor; that the Counsellor is an Independent Contractor and is not an employee or agent of PPC; and that PPC is not
providing counselling services to you. You also understand that your file will be destroyed within five (5) years of your last
visit.
Client’s Signature ___________________________
Counsellor’s Signature _________________________________
Date ______________________________________
T
O BE COMPLETED ONLY BY THOSE APPLYING FOR INSURANCE REIMBURSEMENT
While I understand that some Counsellor, Social Worker or Psychologist fees are reimbursable by some insurance programs I also
understand that:
It is my responsibility to ensure that the Counsellor I am seeing meets the criteria for my particular insurance
policy,
Obtaining such reimbursement is my personal responsibility, and is not the responsibility of my Counsellor,
I am responsible for paying the Counsellor’s fee and submitting my claim personally,
Neither the Counsellor nor PPC is responsible for denied claims.
Client’s Signature ___________________________
Counsellor’s Signature _________________________________
Date ______________________________________
Date ________________________________________________
Last updated 1/25/2007
C:ppcshareFormsBiographical Information Form.DOC
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