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To book an appointment, please view and sign the following consent form:

Informed Consent for Psychotherapy General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with your therapist. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

Description of Services

According to the Canadian Counselling and Psychotherapy Association (CCPA), counselling and psychotherapy involve the skilled and principled use of relationship to facilitate self-knowledge, emotional acceptance and growth and the optimal development of personal resources. The overall aim is to provide an opportunity for people to work towards living more satisfyingly and resourcefully.

Risks and Benefits

Psychotherapy may involve the risk of remembering unpleasant events, feeling unfamiliar sensations, or arouse strong or unanticipated feelings or memories. You may face issues or aspects of yourself that are uncomfortable, and therapy may lead to unforeseen changes in your relationships or take you out outside of your comfort zone to explore and expand your growing edge. Benefits may include an increased ability to live more effectively by improving your ability to cope with a variety of stressors and life challenges. You may also gain a better understanding of yourself, your goals and your values, which will assist you in your personal and career growth. You may experience relief or resolution of trauma symptoms, and develop skills, increased resiliency and a healthier relationship with yourself and others. Additional benefits are described on our website.

Outcomes and Ethics

The outcome of counselling and psychotherapy is difficult to predict or guarantee, since it is dependent on a number of factors, such as the fit between you and your therapist, current adverse conditions that are actively contributing to your symptoms, and your readiness and willingness to work towards set goals. However, Tiffany will do her best to help you to handle the risks safely and experience at least some of the benefits. If you have any questions or concerns, Tiffany encourages you to discuss these with her at any point. You may also direct your questions to the College of Registered Psychotherapists of Ontario. For more information, click on

Age of Consent to Service

Children who are not considered a mature minor are required to have parental or guardian consent to participate in therapy. Whether or not the parents live together or live with the child(ren), the consent of all parents with legal custody is required for their children to participate in therapy. Children who are high school age may be considered a mature minor and may consent to their own care and treatment if they are found to have the ability it understand the risks and benefits of treatment. Otherwise, both parents can provide consent on behalf of the minor.

We respect the privacy of our clients, holds in strict confidence all information about clients and comply with applicable privacy and other legislation. No information will be released to a third party without your prior written authorization. At any time, you have the right to withhold or withdraw consent to, or place conditions on, the disclosure of your information. Exceptions to confidentiality include the legal and/or ethical obligations for your therapist to:


(1) When a client indicates they are at risk to hurt him/herself or others, such as when there is a danger of suicide or assault. In these situations, a therapist may need to take additional steps to ensure safety.

(2) When a therapist has reason to believe that a child under age 16 is in need of protection from physical abuse, sexual abuse, serious emotional abuse or neglect. This includes situations when physical abuse or high levels of conflict are occurring between adult family members and there is a child (or children) in the home. It also includes situations when a client reports that a child is not being adequately supervised and is at risk of harm. It also includes situations when a client discloses that s/he was abused in childhood and there is a possibility that the person who was abusive may be a danger to other children now. In these situations, Family and Children’s Services needs to be contacted.


(3) When a client reports a reasonable suspicion that a resident of a long term care facility regulated by the Long Term Care Facilities Act of Ontario (such as a seniors residence or nursing home) is being physically abused by anyone, and /or has suffered or may suffer harm as a result of unlawful conduct, neglect, or improper or incompetent care by staff in the home. In these situations it may be necessary to report it to the
provincial Director of Nursing Homes.

(4) When a client discloses that s/he has been sexually abused by another helping professional who is a member of a profession regulated by the Regulated Health Professions Act of Ontario (e.g., psychologist, medical doctor, physiotherapist, etc.) or the Social Work & Social Service Workers Act of Ontario, it may be necessary to report the name of the professional (not the client) to the relevant college.

(5) When a therapist is mandated by law to disclose information. This may include situations where a therapist is subpoenaed or ordered to testify in court.

(6) In a situation of the unexpected death or illness of the therapist, you may be contacted by a representative who is acting on behalf of the therapist. This representative will be obliged to ensure confidentiality as the therapist does and will provide you with an appropriate referral.


While these events are rare, they do exist. However, it is our overall goal to make this a place where you feel comfortable to talk about personal concerns. We will also consult with other professionals for guidance specific to the therapeutic modalities she uses, for the purposes of providing you with the highest quality care. Information provided in these other contexts will be anonymous.

Online Therapy
For our sessions, we use a secure videoconferencing line through a program called Zoom or phone calls. If you have opted for a Zoom audio call, prior to our first session you will be sent the link for the call. Prior to our first call, please click on it to ensure it is working. You may be required to do a one-time download of the applicable software. If it does not work for you, please try a different browser. For all online video sessions please ensure that you have a good connection/good reception. For your privacy and to receive the most benefit from our work together, we request that you ensure you have a quiet, private space where you feel comfortable and will not be interrupted or overheard during our session. 

Social Media
Guidelines regarding privacy and confidentiality do not allow therapists to accept requests for personal or professional connections on social media sites such as Facebook or LinkedIn. Though we may use social media sites as a form of advertisement, clients are in no way obliged to participate in these forums.

Record Keeping

Therapists in Ontario are required by law to keep a record of each contact and therapy session with a client. Records are kept for a minimum of 10 years after a client turns 19 years of age. All information is maintained in compliance with the Personal Information Protection and Electronic Documents
Act (PIPEDA) of the Federal Government of Canada and the Personal Health Information and Protection Act (PHIPA) of the Province of Ontario. This means that all personal information obtained, used, and disclosed in therapy sessions is done so with your consent. Your personal information is protected by specific safeguards including locked cabinets and computer passwords. You may request a copy of your records for a reasonable fee. Please note that records cannot be released when they contain the name of another person, and that reports from other professionals cannot be released without the consent of that

Extended Health Insurance

Our services are sometimes covered under extended health benefits. Please verify with your insurance plan if you have coverage for a counsellor (Ontario Association of Mental Health Professionals), for a Registered Psychotherapist - Qualifying (College of Registered Psychotherapists of Ontario), for a master’s level therapist (Master of Spiritual Care and Psychotherapy), or if you have a health spending account. We will collect your payment directly, and you will then be provided with a receipt to be submitted to your insurance company for reimbursement. It is your responsibility to contact your insurance company in advance of starting therapy to determine your annual coverage and whether you need a referral from a medical professional, as each insurance plan is different.

Informed Consent

Informed consent for psychotherapy and counselling is essential and out of respect for your right to choice and self-determination. Consent must be given voluntarily, knowingly and intelligently. You have the right to change your mind and withdraw informed consent at any time, terminate treatment, or refuse a particular treatment modality if you are not comfortable with it.

If you see each other accidentally outside of the therapy office, your therapist will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to your therapist, and they do not wish to jeopardize your privacy. However, if you acknowledge him/her first, he/she will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.


1. I understand that my health care provider wishes me to engage in a telehealth consultation.

2. I am aware of how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. Ever effort is made to ensure security and confidentiality. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. 5. I have had or know I can have a direct conversation with my provider, during which I have asked or can ask questions in regard to this procedure. Any questions have been answered or will be answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.



Zoom is the technology service we will sometimes use to conduct telehealth videoconferencing appointments. By signing this document, I acknowledge:

1. Zoom is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither Zoom nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

3. The Zoom Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

4. I do not assume that my provider has access to any or all of the technical information in Zoom – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Zoom call.

5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.


Statement of Informed Consent

I have read and understand the information presented in this document. I hereby consent to psychotherapy and counselling services offered by Journey With Me Therapy.

Thanks for submitting!

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