There are two main forms that I require my clients to read and sign: The Therapeutic Agreement and Consent to Use Video Conferencing.

These are forms that you would normally read and sign upon your first visit to my office in person. For the purpose of enabling remote consultations, I ask you to do as follows:

1. Read the Therapeutic Agreement on this web page
2. Fill out the form at the bottom and click on the “submit” button
3. The second page containing the Consent to Use Video Conferencing will load. Please read this followup page
4. At the bottom of the page, check off that you have read it and fill in your name, then click the “submit” button again.

THERAPEUTIC AGREEMENT

Beginning Therapy:

Confidentiality: Confidentiality will be maintained at all times with the following three exceptions:

• If you disclose a situation of physical or emotional harm, neglect, or sexual abuse of a minor
• If you disclose a situation in which you or another are in imminent, severe risk of physical injury
• If my records are subpoenaed by court

If you ask me to speak to another healthcare provider about anything related to your work with me, I will ask for a signed Consent form that states the agreed upon limits of what I can disclose.

I may speak to my clinical supervisor about issues related to my work with you but will keep identifying information confidential.

Fees: My fees are $ 125 /50 minute hour and can be paid in cash, by cheque or by e-transfer at each session. I will give you a receipt at your request. If you choose to e-transfer payment you consent to receive an electronic receipt. I may raise my fees from time to time and will discuss this with you as the need arises.

Cancellation Policy: If you do not cancel an appointment prior to 24 hours of your scheduled appointment time, you will be charged in full for the appointment.

Out of Session Contact: If you’re in crisis and need to contact me before our next scheduled appointment, you may do so (cell: 647-272-9754, email: lisa@lisarumble.ca). These contacts will be limited to a brief phone conversation about whatever is happening for you. My usual hours of work are 11:00 AM to 7:30 PM, Monday to Thursday, 11:00 AM to 5:00 PM on Fridays. It is possible that I will respond outside these hours but it may also be the case that I’m not available outside these hours, especially on statutory holidays. If the issue requires more crisis intervention or late night attention, the following are crisis contacts in Toronto: Gerstein Centre: 416-929-5200, hospital emergency departments, or Toronto crisis line: 416-408-4357.

Email/Text Contact: If you choose to email me with information other than that required for booking or rebooking appointments, you do so with the understanding that email is not a secure method of communication and that your written thoughts or reflections will become part of your clinical record.

Please fill out the form below if you agree to the terms of our agreement and consent to beginning therapy. By doing so, you acknowledge that you have read and understood these terms and that there has been an opportunity to discuss them with me prior to beginning our therapeutic work together.