This form must be completed by a PARENT/GUARDIAN,
not by the patient.

Please Note:  

Our online forms use SSL encryption to maintain secure transmission of medical information. Forms must be sumbiited online.

This document will be added to your child's chart in our electronic medical record system. Our electronic medical system is mandated by the Ontario government, professional regulatory, and privacy laws. There are strict rules about data management in electronic medical systems in Ontario, and once information is added to the chart it can not be deleted. 

ALL PATIENTS (Your Child) 
MUST ATTEND EVERY APPOINTMENT

Experts at Possibilities acknowledge the complexity of neurodevelopmental disorders. That means:

• Most of our assessments involve a Clinical Team of both physicians and allied health professionals like Psychologists, Social Workers, and Occupational Therapists 
• There is a cost to our Clinical Team Assessments since allied health professionals are not covered by the Ontario Health Insurance Plan (OHIP). Assessment costs vary from $2500 to $5265 depending on the service.
• Private therapies are available at Possibilities with a team of Psychologists, Social Workers, Occupational Therapists, and Executive Functioning Therapists. Rates range from approximately $145 to $290 per session. Many of these fees are covered by private insurance plans; please check with your insurer for potential coverage. 
• Only the medical portion of our Clinical Team assessments involving the physician is covered by OHIP when a valid health card is presented. 
• Missed appointments and Late Cancellations/Reschedules (less than 3 business days notice) are subject to a fee equal to the service fee of the clinician.
• For all assessments we require a referral from your Family Doctor or Paediatrician.
• Our services are delivered over Video. However, clients must be physically present in Ontario for the Video session.

The Possibilities Clinic requires one Point of Contact Person who will be responsible for arranging all appointments, getting email communications including reminder notifications and who will notifying the other custodial parent. Please ensure our office is notified if there are any changes in the contact information.

I understand that my email address will be used for communication regarding appointment scheduling and confirmation. In the case of sharing medical documentation and/or assessment reports, those will be shared through a secure portal.

Please submit previous assessments listed above:
Attach Documents

List Patient's parents. Indicate all that apply:

List Patient's siblings. Indicate all that apply:

Welcome to the Possibilities Clinic. Whether in person or on secure video, we aim to provide you with professional service in a comfortable, safe, and friendly environment. The Possibilities Clinic is multidisciplinary, meaning we work in teams with professionals across various areas of expertise. A multidisciplinary approach allows us to provide highly specialized, comprehensive, and integrated assessments and treatments. This consent form applies to all the services you may access at our clinic including, but not limited to, Psychology, Psychotherapy, Psychiatry, Family Medicine, Paediatrics, Occupational Therapy, Speech-Language Pathology, Social Work, Psychometry and Education.

Collection and Sharing of Personal Information
Personal information will be collected during assessment and treatment. This information could include identifying information (e.g., name, contact information), test results, reports, progress notes, payment information, and any information collected with your permission from other health care providers. Our records are kept secure in a confidential electronic file and in accordance with legislative health privacy guidelines. Records are kept for a minimum period of 10 years or 10 years past your child’s 18th birthday if your child is a minor at the start of assessment or treatment. You have the right to obtain copies of your file or your child’s file (if under 18 years of age at time of request). All file requests are subject to an administrative fee.

Your consent allows us to share information with all experts involved in assessment and treatment within our Multidisciplinary Care Team. Your information will also be shared with our Administrative Team for booking, billing, and other administrative purposes. 

Your consent also allows us to share information with your referring physician in the community. However, if you would like us to send information, including Assessment Reports, to anyone else outside of the clinic, your written consent on a separate form, authorizing release of information, will be required. 

Assessment Specifics 
Through the use of standardized tests, measures, and interviews, we will attempt to answer the questions that have brought you to Possibilities for assessment. Once we review the information and results acquired during the assessment, a report will be written detailing findings and our interpretations and recommendations. You will have the opportunity to meet to discuss the results, interpretations, and recommendations with members of our Assessment Team. You will also receive a copy of the report.

Treatment Specifics 
The treatment process generally involves an initial intake session with the patient or, in the case of children and adolescents, with parents or legal guardians. At the end of the initial intake session, type of treatment, treatment goals, and frequency and duration of sessions can be determined. For treatment with children and adolescents, some treatments involve working with parents directly, some involve working with children and teens directly, and some involve a combination, working with all members of the family together or in separate sessions. 

Possible Risks, Discomforts, and Benefits of Assessments and Treatments
Your consent indicates that you understand the purpose of the assessment or treatment that you are seeking for yourself and/or your child or adolescent. Assessments and treatments are designed to benefit your daily functioning and support positive outcomes. In the course of an assessment or treatment, interview questions may touch on personal and private matters that could revive painful memories. Your consent implies that you recognize that clinicians and interventionists who carry out assessments and/or treatments with you, your child, or your adolescent have no intention of causing any personal discomfort, but are performing professional tasks that are typical and  reasonable for the assessment and/or treatment being pursued. For some individuals, participation in an assessment or treatment may cause temporary fatigue, physical discomfort, frustration, and/or stress. Our staff will do everything reasonable to minimize any such discomfort. 

If medications are recommended and prescribed as part of a treatment plan, verbal consent will be obtained after the risks and benefits of the medication treatment plan have been discussed, and prior to initiation of treatment.

Limits of Confidentiality
Your referring physician will receive assessment reports and treatment information as part of your circle of care. Beyond your referring physician, information contained within your clinical record cannot be released outside of the Possibilities Clinic without your written permission, except as required by law. Exceptions where information must be released include:

1. Situations where you are a danger to yourself or others
2. If there are grounds for apparent, suspected, or potential child abuse
3. If there are grounds for apparent, suspected, or potential elder abuse if living in a long-term care or retirement facility
4. If you report sexual abuse by a healthcare professional
5. If information is subpoenaed by a court
6. If your file is subject to a review process by licensed peers or a professional licensing body in accordance with Regulatory Professional Colleges
   
   

Teaching Facility Specifics
The Possibilities Clinic serves as a teaching facility for individuals in training in all professional specialties represented at our Clinic. As such, some assessment, diagnostic and treatment procedures you or your family receive may involve a medical resident, a practicum student, a graduate intern, a post-graduate clinician working towards professional licensure, or a trainee in psychometry and associated interventions. In all cases, individuals in training are working under the direction and supervision of  licensed physicians and/or allied health professionals at the clinic. Prior to any session, you will be informed of an individual’s training status and the name of their direct clinical supervisor. In cases where an individual in training is observing a clinical session or performing clinical functions, you retain the right to decline the involvement of the trainee.

Multidisciplinary Team Process
At Possibilities, we offer a unique team approach to diagnosis and treatment. For clients, multiple clinicians from different disciplines form Core Diagnostic and Treatment Teams. Gathering data, reviewing information, measuring skills, making diagnostic decisions, and formulating treatment recommendations are done by each client’s Core Team members. In addition, the Core Team consults additional clinicians at Possibilities—also from multiple disciplines—for additional data review and recommendations during Clinic Rounds before diagnostic and treatment recommendations are finalized and prioritized to support success. Clinicians on the client’s Core Team, as well as additional clinicians consulted during Clinic Rounds, all adhere to standards of confidentiality regarding client information, diagnoses, and treatments.

Our Adherence to Guidelines and Protocols
Assessments at Possibilities follow specific testing protocols, whether they are conducted in person or through secure video sessions. Guidelines for video testing were created based on recommendations from professional consultations, and education provided by licensed clinicians, researchers, and test developers experienced in the provision of video testing and knowledgeable about research supporting the effectiveness of this approach. Research guidelines from published studies on remote testing were also consulted. Measures taken in our video assessments following suggested protocols include, but are not limited to, 1) explaining to parents/guardians their role as facilitators in ways that support technological solutions while preserving the validity of child responses, 2) using shared screens to present testing stimuli, 3) when indicated, sending paper response booklets in sealed envelopes that remain unopened until the examiner indicates they are needed, and 4) having clients seal envelopes on camera after a paper protocol is completed. Our adherence to guidelines and protocols for video testing supports the validity and reliability of the data we collect across assessment sessions. Additional testing guidelines were followed based on Possibilities Clinic Multidisciplinary Team Assessment protocols, specifications outlined in standardized test manuals, and in accordance with professional training in test administration.

 Declaration and Consent

I have read this consent form, understand its contents, and agree to its terms for assessment and/or treatment. Furthermore:

1. I understand that consent is an ongoing process and that I can ask to revisit this continued consent at any point in time in the assessment or treatment sessions.
2. I understand that I have the right to stop the assessment and/or treatment process at any time.
3. I understand that if I am unable to relay, or do not  provide relevant background and health information, this omission may affect the completeness and accuracy of assessment conclusions and any diagnoses made, as well as the effectiveness and safety of treatment. 
4. I have read the Assessment Checklist and understand what I need to provide to ensure accurate testing results.
5. I agree to allow the Psychometry Team to use the secure testing platform (Q-Interactive) to audio record responses articulated on verbal tasks to support accurate documentation, assessment, and scoring. I understand that the audio files will be deleted promptly after the test responses are scored, and no later than the psychology feedback date.
6. The purpose of the assessment is to determine whether the symptoms and functioning being investigated meet criteria for specific diagnoses. I understand that outcomes following the assessment could include 1) no diagnoses being made, or 2) one or more diagnoses being made by the clinicians on the Assessment Team. I understand that completing this assessment does not guarantee that a diagnosis will be made.
7. Substance use influences cognitive skills like attention, working memory, and processing speed which can affect the validity of scores on assessments. By signing this consent form, I agree there will be a refrain from using specific substances on the day of testing with the psychometrist, specifically before or during the testing session. Substances that will be avoided include alcohol, cannabis, hallucinogens, opioids, inhalants, and sedatives.
8. I understand that if any alcohol, cannabis, hallucinogens, opioids, inhalants, or sedatives are consumed before or during testing on the day of the assessment, the testing appointment for that day will be cancelled and rescheduled for a later time. I understand that rescheduling fees will apply. I also acknowledge that rescheduling may affect some or all subsequent appointments with other providers in the block of assessment appointments, which could result in further delays.
9. I understand that the Possibilities Clinic values a collaborative and respectful approach to care and that I am responsible for upholding those values, along with my family, as participating members in our care. I understand that Possibilities has a zero-tolerance policy for violent, disrespectful, abusive, or threatening language and/or behaviour directed towards any of its team members at any time. I acknowledge that all team members are equally valued at the clinic, and essential to the delivery of professional, compassionate, and quality care. I understand that if I or any member of my family demonstrates any language or behaviour that falls within the zero-tolerance policy, I and any family member seeking treatment will be discharged from all services at the Possibilities Clinic.

Welcome!
Thanks for choosing our clinic. We look forward to working with you in creating possibilities! Please read this document carefully. It will help you make the most of your appointment and help us provide you with a successful outcome. Once you’ve read through this document, please sign and submit.

Is a video visit just like an in-office one?
Yes! Like our in-person assessment, the video option provides live access to members of our Multidisciplinary Team who specialize in different fields like psychology, medicine, speech-language pathology and social work. Most of our diagnostic tests and treatments can be done over video. Our experience has been that video appointments are convenient and replicate the in-person experience. At times, however, the clinician may determine that an in-person visit is needed and will discuss this possibility with you.

Is my video appointment secure?
First and foremost, video appointments minimize your risk of exposure to COVID-19 and its variants. As well, being in your own home might be more comforting and reassuring to you or your child than being in an enviromnent that is completely unfamiliar. Video assessments may not work for everyone and in those cases we can offer in-person appointments. With any virtual platform along with benefits there is the risk for potential privacy breaches. We do our utmost to avoid these risks by using secure and encrypted platforms that are licensed for medical settings.

How do I access my video appointment?
If you’ve tested your connection and downloaded the applications for your phone, tablet, or computer, all you will need to do is click on the appointment link that was sent to you. We recommend that you log on through the link 5 minutes before your scheduled appointment. You’ll be automatically connected and placed in a virtual waiting room. Your clinician will admit you into the consulting room at your designated appointment time.

What do I need to do to prepare for my secure video appointment?
We recommend you test your smartphone, tablet or computer well ​before​ your appointment time. There is nothing more frustrating than having to use the first part of your valuable appointment time dealing with technical issues! Our appointments are scheduled in exact time slots, and your appointment time cannot be extended.

What locations do you suggest for the video appointment?
Confidentiality is our utmost concern, and your session needs to be in a private and quiet space to protect you and your family’s privacy. Please ensure that your session takes place in a comfortable setting, with no interruptions or distractions. Video sessions must remain secure—so they cannot proceed if you are in a public space where conversations can be overheard.

Can I see you from anywhere in Ontario?
Yes! Our clinicians are licensed to practice across Ontario and you can be anywhere from Windsor to North Bay. If you are not a permanent resident of Ontario—you can still see us—but you must conduct your session within Ontario.

What if I’m a resident of Ontario but travelling or studying elsewhere in the world?
Our clinicians are only licensed to serve people within Ontario. Even if you are an Ontario resident, we cannot see you while you are traveling abroad or in other provinces. You must conduct your video session while being physically present in Ontario. We are unable to verify your physical location during our video sessions; by signing below you are consenting to this condition and agreeing to attending video sessions only while physically present in Ontario.

Do you have any suggestions for making the most of my video appointment?
If you’re joining as a couple or family, we recommend that you use a tablet or computer (PC or Mac) rather than a smartphone. A smartphone camera doesn’t have a wide enough lens for a clinician to see more than one person at a time. We want to see everybody! And the microphone and speaker on a smartphone are often not strong enough to pick up voices far from the phone. We want to hear from everybody!

If you ​are​ using a smartphone or tablet, please place it on a stable platform in front of you rather than holding it in your hand. Movement from the camera during the session can be distracting, and your session will feel less like an in-person visit. You will also require a headphone if using a smartphone, as smartphone speakers are not loud enough for the Telemedicine platform. 

What if I miss my appointment, or I’m late for the session?
Video appointments are scheduled just like in-person appointments. Your clinician has set your appointment time aside for you. There are clients booked before you and after you—just like in-person appointments—so your appointment time on video cannot be extended if you are late. If you miss your appointment, or cancel with fewer than 72 hours notice (based on business days), you will be charged a cancellation fee.

What if I’ve changed my phone number or email?
If you have changed your phone number or email address, you are responsible for letting us know. We must protect your privacy, so we can only send your appointment information to the contact number or email you’ve given us. If we hear about a change from you, we’ll change your contact information in our file.

 Declaration and Consent

I have read this consent form, understand its contents, and agree to its terms for my video appointments.

Please Note:  

Our online forms use SSL encryption to maintain secure transmission of medical information. Forms must be submitted online.

Thank you for choosing the Possibilities Clinic. We continue to evolve in our processes to help support how we offer and deliver our comprehensive, multidisciplinary services for you. To reserve all of your appointments in advance, we now require a credit card to be kept on file. This new system improves convenience for our clients. It ensures that appointments made for you or your family are reserved well in advance, and that your assessment and treatment is never interrupted due to a missed or late payment.

Please find our guidelines for payment outlined and clarified below.

Payment Method

• The Possibilities Clinic requires a credit card to reserve all Assessment and Treatment appointments. Assessment and Treatment costs vary depending on the service.
• Credit Card information is obtained over the phone and is securely saved in Intuit Quickbooks Online. We do not keep your credit card information in your medical record. 
• If we are unable to process your credit card, future appointments will not occur until all outstanding balances are paid.

OHIP and Potential Insurance Coverage

• Appointments involving a physician are covered by OHIP when a valid Ontario health card is presented. Without a valid Ontario health card, you will be billed for the physician appointments. 
• You will be invoiced for other services you request that are not covered by OHIP, such as Record Requests, completion of Accessibility and Disability Forms, and Multidisciplinary Team Assessments and Treatments that involve allied health and education professionals (e.g., nurses, psychologists, psychotherapists, psychometrists, social workers, occupational therapists, speech-language pathologists, teachers and academic instructors) 
• Many fees may be covered by private insurance plans. Please check with your insurance provider to determine if you have coverage for specific professionals prior to booking your appointments. Possibilities Clinic is not accountable should your insurer decline your claim. Estimate quotes can be provided upon request prior to booking appointments.

Payment Processing and Confirmation

• Confirmation of all payments will be emailed to you via Intuit Quickbooks Online. Receipts can be downloaded from the email. Please keep a record of your receipts.
• All Assessment, Treatment and Service payments will be processed on the date of your appointment or service provided, as listed on your invoice, once your appointment has ended/service is completed or on the next business day using the credit card information you have provided.

Cancellation Process

• To avoid being charged for appointments you do not attend, we require advance notice of at least 3 business days
• You will be invoiced the session fee for missed appointments, late cancellations, or late rescheduling of appointments made with fewer than 3 business days’ notice. Your credit card will be processed on the next business day.

I have read the Payment Policy and guidelines and agree to the terms.

Please be aware that all children under the age of 18 years require parental/guardian consent to access services at our clinic.  

Both parents' signatures are required, including situations where parents are separated or divorced and there is joint custody or no formal custodial arrangement.  

Each parent may sign separate custody consent forms. However both parents' signatures are required before services can be provided. Unsigned forms will not be accepted.

If both parents/guardians are unable to sign this Custody Consent form, please refer second parent/guardian to our website, possibilitiesclinic.com, under All Forms > Consent Forms > Custody Consent form.  

 Declaration and Consent

I/We, being the custodial parent(s)/guardian(s) of the above named child, consent to the assessment and/or treatment services of said child at the Possibilities Clinic.

Thank you for taking the time to complete the Intake and Consent forms.

Pleae print or save a copy of these Intake and Consent forms prior to submitting in case there are any technical issues that interfere with your submission. If, for any reason, there are any technical issues and we do not receive your submitted forms you will then be able to either submit your saved forms to us through our Attach Document portal on our website or via fax. This will save you from having to complete the Intake form again.

After clicking on the Review Button below, you will see a Print/Save button option that you can use.  Once printed or saved, you must then Submit your forms.