Carefully read the forms below and sign your name. This shall constitute your electronic signature.


I, hereby request and agree to participate in individual psychotherapy with BNJ Holistic Counselling & Wellness Centre.

  • I understand that psychotherapy requires that I discuss my problems and difficulties with a psychotherapist, who will endeavor to provide a supportive, empathic environment and listen attentively.

They may pay particular attention to my feelings, thought patterns, and ways of interacting in the world and

may point these out to me so that I may gain increased understanding and awareness of how events in my

life are impacting on me. The psychotherapist will not offer advice or solutions to the problems that I am confronting, but will try to assist me to come to the best decisions and solutions for my particular situation.

  • I understand that I am free to ask questions about treatment at any time throughout the treatment


  • I understand that treatment is likely to help but that this cannot be guaranteed in my particular case. If treatment is not effective, I understand that I will be referred for further treatment if I wish.
  • I understand that talking about my problems and difficulties may be difficult and painful at times, and

that I may feel distressed during treatment.

  • I understand that I can withdraw from treatment at any time and that if I withdraw, another appropriate alternative or referral will be provided if I wish to continue psychotherapy.
  • I understand that treatment is provided by BNJ Holistic Counselling & Wellness Centre.
  • I understand that by attending and participating in sessions, I am giving my consent for psychotherapy



I understand that all information regarding my treatment (including all verbal and/or written exchanges) will be kept confidential, except under the following circumstances. In each of these circumstances, my psychotherapist will endeavor to notify me of the need to break confidentiality:

  • If I indicate that I may be a danger to myself or others;
  • In the case of apparent or suspected abuse of a child under 16;
  • If a known sexual perpetrator is in close contact with a child under 16.
  • If I report sexual abuse on the part of a health care professional.
  • If my records are subpoenaed by a court of law.
  • If the records of my psychotherapist are randomly audited by the CRPO.
  • I understand that in order to maintain my confidentiality, my psychotherapist will not initiate contact with me in any private or public setting outside of treatment. Rather, I can initiate any contact outside of therapy based on my level of comfort.
  • I understand that it may be advisable to not initiate contact in the presence of others in order to maintain my confidentiality.
  • I understand that my consent is required in order for communication regarding treatment with others, including other health care professionals.
  • I understand that this consent can be provided
  • verbally or in writing, but that my psychotherapist’s policy is to obtain my written consent whenever possible.



  • I understand that the fee for service is $___150___ per 50-minute therapy session plus HST. Based on sliding scale we agreed upon.
  • Payment is due at the beginning of each session, payable by e-transfer. I will be provided with a receipt for services rendered at the end of each session or as needed.



  • I understand that I am required to give 48 hours’ notice for appointment cancellations or changes in order to offer my appointment time to another client. I understand that if I cancel an appointment within this 48-hour period, or miss a scheduled appointment, I will be billed for the session.



  • I understand that I can contact my psychotherapist, at BNJ Holistic Counselling & Wellness Centre by email or by phone. Messages will be responded to during business hours.


My signature indicates that I have read and understood the contents of this form, that I have had the opportunity to ask questions and these questions have been answered to my satisfaction, and that I freely agree to participate in individual psychotherapy.


DISCLOSURE STATE - Member College of Registered Psychotherapist

Welcome to BNJ Holistic Counselling & Wellness Centre Inc. In our interactions with people, we have come to realize that clients need a safe place to talk and feel heard; and before they can do that, they need to know that they can establish and build trust in a therapeutic relationship with their therapist. Hence, there has to be clarity and openness. We are providing the information below so that you are duly informed about your rights as a client. Please go through the information carefully and if you need any clarification, do let us know before you sign.

Education, Training, and Experience: Some of our modalities include Humanistic therapy, Behavioural Therapy, Cognitive Therapy, and Psychodynamic Therapy. Our work is a collaborative one, where we both work together to achieve your therapeutic goals.

Appointments and Cancellation: Appointments can be scheduled over the phone or via email. We need 24 hours if you have to cancel, if you cannot make the appointment fees will still be charged.

Confidentiality: Sessions are held online, by phone and in my office. They are held in the strictest of confidence and We will not release any information about you without your consent. Although, we have some exceptions by law that we have to report. Some of these exceptions include: situations of harm done to self or others, suicidal ideation, and child abuse will be reported to CAS (Children Aides Society) and if we are subpoenaed by law, we have to break confidentiality and release information if the law demands it. Virtual, over the phone and online: we will ask that you get a private space for your sessions, or if you cannot find one, then you can get a headphone to ensure that your sessions are in confidence. We will also ask that you use your private connection and not public WIFI, to ensure your sessions kept privately. We will advise that your sessions should not be taken in restaurants or at work, all these is to protect your privacy. In regards to virtual session, if at any point we have difficulty connecting, please wait for about 5-10 minutes. If we take more than 10 minutes, we will let you know when we will reschedule, or alternatively ask if you can switch to a phone session, this we will clarify before the session begins. In the situation where we cannot see you, and we go via phone, we will be asking you some questions. Prior to starting the session, we will assign a pass code, in order to recognize you. During the phone session, we will be asking you for the pass code.

Fees and Record of Payment: Individual sessions are $150; Couples is $190 and Family is $185 and up; Group sessions are $225 for 50- 60 minutes per session.

In some circumstances, we do offer a sliding scale depending on your financial situation. Payments should be made before the session begins and receipts are given. We accept e-transfer to (to insert). WE do not deal with insurance directly but we can accept payments from your insurance if they cover psychotherapy. We will provide you with a receipt and you can send it to your insurance company. Also, we will advise that you confirm that your insurance covers psychotherapy before we proceed.

I have read the disclosure statement for BNJ Holistic Counselling & Wellness Centre and all my inquiries have been answered.