Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address of Residence *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone Number *

Country

(###)

###

####

Emergency Contact Person *

First Name

Last Name

Emergency Contact Phone Number *

Country

(###)

###

####

Limits of Confidentiality *

Everything you tell me, Julia Zheretiy is confidential. However, there are a few exceptions or circumstances in which I cannot maintain confidentiality. As professional, I am required to disclose confidential information if any of the following conditions exist: 1. If you tell me about a child who has been abused or is being abused, I have to report this to the Children’s Aid Society 2. If you disclose that another health care provider has sexually abused you, I have to report it to the appropriate college 3. If you tell me that you are planning to harm yourself or someone else, I have to intervene to make sure that you and/or the other individual is safe 4. If for some reason you are involved in a court care, your records may be subpoenaed. I will do everything I can to keep you records confidential, but sometimes it may be out of my control to do so. If you have any questions about these limitations, please discuss them with me.

I have read and acknowledged the Limits to Confidentiality

Consent to Psychotherapy *

I take full responsibility to inform my therapist about any physical, mental or emotional conditions that may affect my participating in and receiving Psychotherapy and/or Life Coaching (“Therapy”). I understand that this work does not constitute medical treatment but rather is a form of health maintenance using Psychotherapeutic and Coaching Techniques, and that my licensed Medial Doctor is my primary source for health care. I have discussed all questions with my therapist, Julia Zheretiy, and my signature below constitutes informed and knowledgeable authorization and consent to receive Therapy. I hereby consent to submit myself to Therapy to be administered by Julia Zheretiy to help me deal with any issue that is brought to the sessions. I acknowledge and understand that by using therapeutic techniques, this session and subsequent sessions using this modality, may results in uncovering some troubling memories. However, the focus of the sessions is one of exploration, healing and moving forward. I accept full and complete responsibility for every result, now and in the future, resulting from techniques used, abiding by the code of ethics held by Canadian Examining Board of Health Care Practitioners and The College of Registered Psychotherapists of Ontario administered by Julia Zheretiy. I hereby forever and unconditionally release Julia Zheretiy from all claims and causes of action related to or arising from the Therapy now or at any time performed by Julia Zheretiy. I accept any and all risks for any adverse reaction I may have to Therapy. I acknowledge and agree to the terms and conditions contained in this Consent form. I understand that online models of communication such as Skype, FaceTime, Google is not fully safe and confidential form of communication and I release Julia Zheretiy of all responsibilities related to communication via such medium.

I agreed to all of the above statement and conditions, and I am consenting to receiving Therapy.

Payment for Services *

I agree to pay for all consultations provided to me at the agreed upon rate per hour. This rate includes HST. There is a 12 hour cancellation policy. If you cannot attend your appointment please notify me 12 hours in advance, otherwise you will be charged the full amount of the session. My payment options are - Interac Email Money Tranfer to juliazheretiy@gmail.com - Cash or Check - Pre-authorized charge to Credit Card Fees may vary according to the time and nature of the service(s) involved and you will be advised in advance if any changes are made to the fee.

I agree to pay in full at the end of each session, unless another arrangement is agreed upon.

Video Therapy

I agree to engage in video therapy when applicable. I understand that video conferencing technology will be used. I understand that such consultation will not be the same as an in-person visit due to the fact that I will not be in the same room as my therapist. I understand there are potential risks to using online technology such as interruptions, unauthorized access by third party, and potential technical difficulties. I understand that Julia or I can discontinue the use of video therapy sessions. I have had the opportunity read the information about video therapy at www.juliazheretiy.ca/online-therapy. I also have had the opportunity to ask questions prior to the session by booking free 20 minute consultation online or over the phone, emailing and/or scheduling a phone call prior to the video session. I agree to ask for an consent and agreement from Julia to use any recording equipment to document any parts of the video therapy session for any reason.

I have read the statements regarding risk of Video Therapy, I agreed and I am consenting to receiving Video Therapy.

Cardholder's Name *

First Name

Last Name

Authorization to Charge *

I hereby authorize Julia Zheretiy, RP to charge my credit card above for agreed upon amount. I understand that my information will be saved in my personal confidential file for future transactions on my account.