<p>9915B-82 Ave, Edmonton, AB T6E 1Z1 www.allegrocounselling.com [email protected] 587-907-8944</p><p>A G R E E M E N T F O R P S Y C H O L O G I C A L S E R V I C E S</p><p>Client(s) Name: ______</p><p>Date of Birth (mm/dd/yyyy): ______</p><p>Agree to the following services (circle one): Individual Therapy ❖ Relationship Counselling ❖ E-Counselling </p><p>Children’s Therapy ❖ Psychological Assessment Admission Date (mm/dd/yy): ______</p><p>Insurance Provider: ______Insurance Provider Phone Number: ______</p><p>Insurance Policy Number: ______Insurance Coverage Amount: ______</p><p>I/we acknowledge, consent to and authorize the following:  The above-named services  That a complete orientation to the above services, including a verbal description, a discussion of the risks and benefits of treatment, other options for treatment, and policies and procedures regarding confidentiality of my information has been given to me  That emergency medical attention and first aid may be given, in the event that this is required</p><p>Confidentiality Agreement I / we the client(s) understand that information shared with the Employee / Therapist - including but not limited to, formal psychological reports, evaluations, assessments and tests shall remain confidential and will not be disclosed to anyone without the Client's explicit written consent, unless one of the following situations arise: risk of harm to the Client, a child or any other individual, subpoenas and court ordered demands for disclosure of the client file, evidence that the security or development of a child (or vulnerable adult) has been abused or is in danger of abuse. The client understands that in these situations the Employee / Therapist is obligated to contact close family members or other significant others, seek hospitalization, contact police or governmental agencies in accordance with the laws of the Province of Alberta. In the event that two or more individuals are jointly seeking counselling services for their relationship(s), the client understands that the Employee / Therapist shall not withhold any relevant information from either individual. In the event that a breach to the filing system of Allegro Counselling occurs, each client of past and present will receive written notice. The client consents that the Employee / Therapist receive regular supervision for the purpose of ensuring adequate care to the client and their families from affiliate members. 9915B-82 Ave, Edmonton, AB T6E 1Z1 www.allegrocounselling.com [email protected] 587-907-8944 Agreement to Services Indemnity During the first session you will sign an agreement to services for Allegro warrants indemnifying the Client in the event that a your therapeutic needs. Each client is made aware of the risks and malpractice occurs against the client or child if applicable - and agrees benefits of counselling treatment and has the ability to discuss to reimburse Allegro for any and all legal fees resulting out of a this verbally and ask questions. malpractice or liability suit(s) if judgment is ruled in favour of Allegro or 3rd Party Consent the client. If your Therapist needs to speak to a 3rd party such as your family doctor, your case worker or CFS, you must sign a consent form authorizing disclosure of your file for third party contact.</p><p>I/we have had the opportunity to ask questions about this form, the services being provided, and all of the other information regarding confidentiality and liability. All of my/our questions have been answered to my/our satisfaction.</p><p>(Consenting to services for youth 16 and younger)</p><p>______Parent/Guardian Date Witness to Parent/Guardian</p><p>______Parent/Guardian Date Witness to Parent/Guardian</p><p>______Client Date Witness to Client</p><p>______Client Date Witness to Client</p>