Affordable, private and secure online counselling. Anytime, anywhere.

Contact Info - child/teen

Last Name*

First Name*

Youth's date of birth*

Youth's gender*

Male
Female
Other

Youth's gender

Youth's age*

If this appointment is for an adult (<21 years old), please fill out the intake form for an adult.

Please enter a number from 0 to 21.

Grade level*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Youth's phone number*

Youth's email address*

Was the child/teen born in Canada?*

Yes
No

Where was the child/teen born and when they come to Canada?

Contact Info - Parents

Mother's full name*

Mother's phone number*

Mother's email address*

Father's full name*

Father's phone number*

Father's email address*

Background information - child/teen

School attended*

Please provide names of all schools your child attended (please include school board or city where schools are located

List Youth's strengths and interests*

List Youth's weaknesses*

List all your concerns related to your child's/teen's development

Fill out if relevant

List all your concerns related to your child's/teen's emotional well being

Fill out if relevant

List all your concerns related to your child's/teen's behaviour

Fill out if relevant

Is there a history of mental health problems in the family? Please describe

Fill out if relevant

List all your concerns related to your child's/teen's school functioning

Fill out if relevant

Please upload all related documents such as report cards, medical notes, previous assessments etc.

Drop files here or

Max. file size: 64 MB.

About the Family

Who lives with the youth at home?*

Please put names and ages

List all languages spoken at home*

Mother's Occupation*

Father's Occupation*

CORE CENTRE INC. DOES NOT PROVIDE ADVICES OR ASSESSMENTS FOR CUSTODY AND ACCESS.*

I understand and agree

Who holds the custody?*

Only mother
Only father
Both parents
Other

I herby that all legal guardians/custodians provide the consent that psychological services are provided to the child/teen.*

Yes
No
Other

Is there a court document that indicates custody and access arrangement?*

Yes
No
In the process

Please provide us wth any legal documents pertaining to the child/youth.

Please upload this document here or send it to us via email or fax. It must be submitted and reviewed before any psychological services are rendered.

Drop files here or

Max. file size: 64 MB.

Developmental History

Below are some questions related to your child's/teen's birth and development.

Were there any problems during pregnancy and/or delivery?*

Yes
No
Other

Please describe if there were any problems with pregnancy and/or delivery*

At what age your child/teen started to walk?*

He/She started walking at the normal time limits
His/Her motor skills were somewhat delayed
Before 1 year of age
Before 2 years of age
After 2 years of age
He/She received Occupational Therapy services
Other

At what age your child/teen started to talk?*

He/She started talk within the normal time limits
His/Her speech and language development was delayed
Before 1 year of age
Before 2 years of age
After 2 years of age
He/She received Speech Therapy
Other

Vision*

His/Her vision has been checked: and reported normal
His/Her vision has been checked: needs glasses
His/Her vision has NOT been checked
Other

Hearing*

His/Her hearing has been checked: and reported normal
His/Her hearing has been checked: and there are some problems
His/Her hearing has NOT been checked
Other

In what Psychological Services you are interested in?*

How did you hear about us?*

Please provide the name of the physician who referred you to us.

Please provide the name of the friend who referred you to us.

Your informed consent is needed to provide our services and to keep records of your personal information. This process informs you of the services we agree to, the records we will keep, and the costs to you. Please ask any questions.The informed consent discussion covered all issues checked:*

Below are some important information for you to understand the process, nature, risks, and benefits of psychological services in order to make an informed decision about participating in them. These information are also available on our websites www.corecentre.online and www.corecentre.online.

Core Centre Inc. is pleased to offer services to youth and adults through distance delivery (“virtual services”, “telecounselling”, Telepsychology, Teletherapy) – either via videoconferencing or telephone. The platform that we are using is Zoom. Zoom is a third- party video communication service that uses industry standard privacy and security measures. For additional information regarding their privacy standards and tips on privacy, visit the following link: https://zoom.us/privacy.

Your informed consent is needed to provide our services and to keep records of your personal information. This process informs you of the services we agree to, the records we will keep, and the costs to you. Please ask any questions.

Your First Appointment
During your first appointment your counsellor will discuss the initial consent form with you (attached). This provides you the opportunity to ask questions or express any concerns you might have. The remainder of the session is spent gathering information about your presenting concerns(s) and/or need(s) and exploring expectations of your work together. Counselling appointments are 50 minutes in length.

Virtual Services
Definition of Services: Virtual Services (also known as, Telepsychology, Teletherapy) is a form of psychological service provided via secure internet technology. It has the same purpose or intention as psychotherapy or psychological treatment sessions that are conducted face-to-face at the offices of Core Centre Inc.. Due to the nature of the technology used, Virtual Services services may be experienced somewhat differently than face-to-face treatment sessions. Virtual Services involves arranging an appointment time with the client at their computer and the psychological service provider (therapist) interfacing from their computer via the internet.

Note: The Ontario Psychological Association has recognized the provision of psychological services using telecommunication technologies that allow for the preparation, transmission, communication of processing of personal health information by electronic means. These technologies may include telephone, mobile devises, secure videoconferencing, secure forms of email, text, chat and some internet-based services (e.g., social media).

For more information on the use of email, please refer to the OPA Guidelines on Best Practices in Electronic Communications. https://bit.ly/33u6TQF
For more information on the use of social media, please refer to the OPA Guidelines on Best Practices in Social Media. https://bit.ly/2WukVQC
For more information on the use of social media, please refer to the OPA Guidelines on Best Practices in TelePsychology. https://bit.ly/2U12y4i

Core Centre Inc. therapists will use HIPPA compliant video services.
The client is responsible for securing his or her own computer hardware, internet access points, and password security.

The company is not liable for confidentiality breaches when they are caused by client error.

The company is not responsible for their client’s equipment failure, e.g. camera, and/or Internet service.

The company is not responsible for lapses in confidentiality that are in direct response to the client’s actions.

Disconnection Problems
If video services are not available due to an unplanned equipment or service malfunction, sessions will occur via telephone.

Recordings Are Prohibited
Clients are not allowed to make an audio or video recording of any portion of the session.

Client Requirements
Client, need to be a resident of Ontario. Most of the virtual sessions need to be conducted in Ontario. If you are vacationing or visiting outside of Ontario, you can use Virtual Services to have a session or two with your therapist. For example, if you winter in Florida but see your therapist at other times of the year, you can have sessions during your stay in Florida.

Clients who are actively at risk of harm to self or others are not suitable for Virtual Services. If this is the case or becomes the case in future, speak to your treatment provider and more appropriate services will be provided or recommended.

Risks and Rights in using Virtual Services
1. You have the right to withdraw consent at any time. It will not affect your right to further treatment.
2. The therapist (or, psychological service provider) has the right, at any time, to determine if Virtual Services sessions are not appropriate for your case. Should this be determined, they are obliged to continue with face-to-face services or provide referral information to other services.
3. The laws and professional standards that apply to regular psychological services apply to Virtual Services services. See www.cpo.on.ca for further information.
4. There are exceptions to client confidentiality policies that exist for regular therapy; these also apply to Virtual Services services. If you need more information on such exceptions, please consult with your therapist.
5. Despite best efforts to ensure high encryption and secure technology, there is always a risk that the transmission be breached and accessed by unauthorized persons.
6. There is a risk that services could be disrupted or distorted by unforeseen technical problems.
7. There is a risk of being overheard by anyone near you if you do not place yourself in a private room. You, the client, are responsible for creating a comfortable safe environment on your end of the transmission. It is the responsibility of the psychological treatment provider to do the same on their end.
8. Due to the nature of the interaction, there may be quality differences that are experienced when compared to face-to-face services. You may provide feedback to your therapist should you find the quality insufficient for your needs.

In-Person services (Assessments)
Assessments are conducted partially on-line (consultation and feedback/final sessions) and in-person (testing).
For in-person appointments we screen clients over the phone before scheduling or confirming appointments for any symptoms and travel history that may be related to COVID-19. Clients are also asked to fill out the screening questionnaire: https://forms.gle/V7JrvzGWkrLsNZLv9.
Assessments are delivered with the examiner and examinee facing each other through a Plexiglas screen.
When possible assessment stimuli are displayed on a iPad or computer monitor located to the right of the Client. Otherwise, they are presented from as per standardized procedures. Both the examiner and examinee are wearing personal protective equipment (i.e., cloth face masks) as per Core Centre Inc. policy.

Core Centre Inc. took several steps in order to to reduce the risks of spread of COVID-19 and to protect our clients and personnel (see Core Centre Inc. Covid policy).

Who Can Access Your Information and How it is Stored?
All client files are stored in the secure electronic database. Administrative support staff have access to initial documents completed upon entry into counselling, but cannot access details about client’s sessions. Our administrative assistants are bound by an oath of confidentiality and never have the right to release client’s information to anyone other than the counsellors within the agency. Information Technology (IT) has access to the server but does not have access to specific client information. Our filing policy is as follows:
All files are stored electronically.
If you are a returning client your former paper file will either continue to be locked in a filing cabinet, or be scanned into the electronic storage. Your file will be closed when you and your counsellor complete services, or if we have not heard from you after 30 days.
Psychological record file consists of notes and test protocol forms until later of 10 years after last contact or age 28.

Counselling & Confidentiality
We protect your privacy: We are not allowed to tell people if, or why, you are seeking our services without your consent. However, there are times when the counsellor may not be able to protect your privacy as identified below.

Important Limits to Confidentiality
A. You give us written permission to share details about you to others (e.g., an academic
advisor, your doctor). You have the right to change your mind and revoke that permission at any time.
B. We use non-identifying facts about you (e.g.,demographics) to compile statistics that
may be used in professional publications and/or presentations.
C. Your counselling file is subpoenaed. We may advocate limiting the information admissible, but the court system has the ultimate right to access your file.
D. You share information that implies; (a) you are in imminent danger of harming yourself or someone else; (b) someone you know may be in danger (e.g., is being abused, threatened, neglected, or is witnessing abuse) such as dependent adult, family member, person under the age of 18, and/or animal; (c) there are criminal activities (past or current) that pose a risk to the safety of people; (d) there is maltreatment of a client by a helping professional.
E. We receive information from a concerned third party (such as security or a friend), or on social media that implies you may be at risk for engaging in behaviors that may threaten your or others’ safety. In such cases, we may need to discuss these concerns with relevant parties. It is important you know our counselling team is very cautious about releasing information about you to others so only the minimal amount of information will be released and recorded in your counselling file. Based on clinical judgment the counsellor may choose not to inform you about information received from third parties.

If you have any questions about these exceptions to your privacy, please ask us — we are devoted to protecting your rights.

Release of Information Forms
Should you or your counsellor wish to discuss your situation with another individual or agency, you will need to complete a release of information form stating who they are allowed to speak with and the type of information they can release. If your counsellor is writing a letter on your behalf, you will have an opportunity to review the letter and may request a copy for your own records. Often you will be expected to take the letter to the other party yourself, as opposed to faxing or mailing options.

Mature Minor
If you are under the age of 18, the law states that your legal guardian(s) may have the right to be informed of the contents of your client file. In this case, your counsellor will take additional steps to protect your privacy. In some cases, your counsellor will be able to determine that you are a mature minor, which means that you will not need consent from your legal guardian(s) to receive therapy. The counsellor will determine your mature minor status based on your understanding of the nature of therapeutic treatment, the risks and benefits to therapy, and your ability to apply your own values when you make decisions. If you are not a mature minor then your counsellor will ask you to get a signature from your legal guardian(s) before your next scheduled session.

Fees and services
Our fees are set in accordance with the guidelines put forth by the professional associations and they range from $150 to $280 depending on the service, provider, number of clients and length of the visit.
A fee for a 60 min. session with a registered psychologist is $280.00 per hour.
A fee for a 60 min. session with a registered psychotherapist is $200.00 per hour.
A fee for a 60 min. session with a registered social worker ranges between is $150 and $200 per hour.
A fee for 90 min. for a couples and marriage therapy with a registered psychotherapist is $250.
These rates are charged for all direct and indirect contacts, either in the context of treatment or assessment.
An hour of treatment includes 50 minutes of face-to-face contact and 10 minutes for me to document my activities.
Billing will also occur for services done outside the therapy hour, such as phone calls, letters and they are calculated at hourly rate for each hour.
There is a $20.00 fee for preparing duplicate statements.
There is a $50.00 fee for preparing specialized fee statements or receipts
Our fees are not covered under OHIP. If you have extended health insurance, check with your insurer for details of your coverage for assessment and counselling by a registered Psychologist or Psychological Associate or Psychotherapist.
Fees for a Psychological Services are income tax deductible as medical expenses. Save your fee statements to submit.
All fees should be paid at the time the service is booked or rendered.
Credit card payment , E-transfer, cash or personal checks are welcome.
Fees not paid after 30 days are subject to 5% interest charge indicated on the fee statement. Any accounts that are turned over for collection will include reasonable collection fees.

Canceled appointments
Any appointment Client cannot keep must be cancelled more than 48 hours before the scheduled time. Cancellations may be made by e-mail or phone call. Clients can also leave a voice message at (647)515-4357.
Clients will be billed for an appointment if it is missed or cancelled with less than 48 hours notice.
Clients will be billed $500 if the assessment session is missed or cancelled with less than 48 hours notice.
Please note: if you are more than 15 minutes late for your appointment, your session will be cancelled and you will have the opportunity to reschedule.The late cancellation fee will apply.
Doctor’s note is required to wave these fee.
Any therapist/counsellor can refuse treatment to anyone for any reason if they do not feel they are adequately equipped to help, or believe that the Client may need a higher level of care. If mental health professional believes that the Client would be better served by another form of psychotherapeutic services, the Client will be referred to an alternate professional or service who can better meet Client’s needs.
On rare occasions, therapist/counsellor may need to cancel appointment due to a personal, professional or family emergency. In this situation, Core Centre Inc. will try to inform the Client in a timely manner about the cancelation and help the Client to reschedule the appointment and/or transfer Client to another counsellor.

OUR FEES AND SERVICES:

A fee for a 60 min. session with a registered psychologist is $280.00 per hour.
A fee for a 60 min. session with a registered psychotherapist is $200.00 per hour.
A fee for a 60 min. session with a registered social worker ranges between is $150 and $200 per hour.
A fee for 90 min. for a couples and marriage therapy with a registered psychotherapist is $250.

These rates are charged for all direct and indirect contacts, either in the context of treatment or assessment.
An hour of treatment includes 50 minutes of face-to-face contact and 10 minutes for me to document my activities.

Billing will also occur for services done outside the therapy hour, such as phone calls, letters and they are calculated at hourly rate for each hour.
There is a $20.00 fee for preparing duplicate statements.
There is a $50.00 fee for preparing specialized fee statements or receipts

PAYEMENTS FOR SERVICES:

All fees should be paid at the time the service is booked or rendered.
E-transfer, cash or personal checks are welcome.
Credit card payments are also available (3% will be added).
Fees not paid after 30 days are subject to 5% interest charge indicated on the fee statement. Any accounts that are turned over for collection will include reasonable collection fees.

CANCELLED APPOINTMENTS

Any appointment Client cannot keep must be cancelled more than 48 hours before the scheduled time. Cancellations may be made by e-mail or phone call.
Clients will be billed for an appointment if it is missed or cancelled with less than 48 hours notice.
Clients will be billed $500 if the assessment session is missed or cancelled with less than 48 hours notice. Doctor’s note is required to wave these fee.

IMPORTANT:

Our fees are not covered under OHIP. If you have extended health insurance, check with your insurer for details of your coverage for assessment and counselling by a registered Psychologist or Psychological Associate or Psychotherapist.
Fees for a Psychological Services are income tax deductible as medical expenses. Save your fee statements to submit.

I will pay Core Centre Inc. in full at the time when I book my appointment and/or when the service is rendered.
I will pay for missed sessions that were not cancelled 48 hours in advance an hourly fee and $500 fee for no-show for the assessment.
I have received a copy of Core Centre’s fee schedule.

If you have any questions regarding the above information, please feel free to ask.

By typing my name on this form, I am entering my "electronic signature" (as defined in the Uniform Transactions Act, C.R.S 24-71.3-101 through 24-71.3-121) and certifying that I have read, understand and accept the terms of this program enrolment.

I have read, understood and agree with the above.

Consent to engaging in virtual services*

I hereby consent to engaging in virtual services (aka. TeleHealth, TelePsychology) and/or in-person services with the mental health team at Core Centre Inc. As part of my mental health care, I understand that virtual and in-person service includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video or data communications.

I agree

Alternative referrals*

I understand that services provided by Core Centre Inc. are confidential and that there are some rare exceptions to these commitments.

I agree

Collecting personal information*

I understand that to provide me with services through Core Centre Inc. will collect some personal information about me (e.g., home telephone number, address). The Core Centre Inc. has described its Privacy Policy about the collection, use and disclosure of personal information, steps taken to protect the information and my right to review my personal information (https://corecentre.ca/privacy-policies/).

I agree

Using personal information*

I agree to Core Centre Inc. collecting, using and disclosing personal information about me as set out above and in their Privacy Policy.

I agree

Confidentiality*

I understand that services provided by Core Centre Inc. are confidential and that there are some rare exceptions to these commitments.

I understand

INDICATION OF INFORMED CONSENT*

By typing my name on this form, I am entering my "electronic signature" (as defined in the Uniform Transactions Act, C.R.S 24-71.3-101 through 24-71.3-121) and certifying that I have read, understand and accept the terms of this program enrollment.

I agree

I have read this Informed consent document*

I have read this Informed Consent document. (I understand that I will be able to ask my counsellor questions for clarification.) I agree to engage in counselling under the conditions outlined in this document.

I agree

Your Signature*

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Contact Info - child/teen

Contact Info - Parents

Background information - child/teen

About the Family

Developmental History