Pauline O’Brien’s Psychotherapy Consent and Service Agreement

Last revised: October 23, 2026

This agreement explains my psychotherapy services, your choices, confidentiality, fees, and practice policies. We will review the information together, and you are welcome to ask questions before signing or at any point during our work.

Professional disclosure

I am a Registered Psychotherapist with the College of Registered Psychotherapists of Ontario (CRPO #001225) and have more than 20 years of experience working with youth, adults, and families.

I hold an Honours Bachelor of Arts (BA) in Psychology (2002) and a Master of Education (M.Ed.) in Counselling (2004) from the University of Ottawa, as well as an Ed.D. in Counselling Psychology from the Ontario Institute for Studies in Education, University of Toronto (2016).

I am also a Canadian Certified Counsellor-Supervisor (#249). My professional work includes psychotherapy, clinical supervision, and teaching in Yorkville University’s Master of Arts in Counselling Psychology program.

CRPO regulates Registered Psychotherapists in the public interest, establishes professional standards, and considers complaints about registrants.

Nature and purpose of psychotherapy

Psychotherapy is a collaborative process intended to support your wellbeing, understanding of yourself, relationships, and ability to respond to difficulties. My approach is relational, trauma-informed, and responsive to your identity, culture, circumstances, strengths, and preferences. Where appropriate, we may discuss parts-oriented, somatic, or other therapeutic approaches.

Together, we will discuss your goals, the approaches proposed, their purpose, and whether they are suitable for you. We will review progress and adjust our work as needed. The frequency and duration of therapy depend on your needs, preferences, progress, and available resources.

Psychotherapy does not guarantee a particular outcome.

Potential benefits, risks, and alternatives

Possible benefits include greater self-understanding, improved coping, reduced distress, stronger boundaries, and changes in relationships or longstanding patterns.

Therapy may also involve uncomfortable feelings, difficult memories, uncertainty, fatigue, or changes in how you understand yourself and your relationships. Some people experience increased distress during treatment. Increased distress is not inevitable and should not automatically be understood as a necessary part of progress. Please tell me about any concerns so we can review safety, pacing, and the treatment approach.

Alternatives may include another therapist or therapeutic approach, group or community support, medical assessment, other health services, self-directed resources, or choosing not to proceed. We will discuss alternatives relevant to your situation and the possible implications of delaying or declining treatment.

Your choices and ongoing consent

Participation is voluntary. You may ask questions, decline to discuss a topic, refuse a particular intervention, request a different approach, pause treatment, or withdraw consent at any time.

Consent is an ongoing conversation. Signing this agreement does not mean agreeing in advance to every intervention. I will seek renewed consent when relevant aspects of treatment change and document our consent discussions.

Capacity to consent and services involving youth

Capacity to consent depends on the person’s ability to understand relevant information and appreciate the reasonably foreseeable consequences of a decision. Age alone does not determine capacity to consent to treatment in Ontario.

Where a client cannot consent to a particular decision, I will identify and involve the appropriate legally authorized substitute decision-maker. The client will remain involved as fully as possible.

For youth services, we will clarify consent, confidentiality, parental or caregiver involvement, access to records, and payment arrangements before treatment. Paying for services does not automatically entitle a parent, caregiver, or other person to confidential information.

Confidentiality and its limits

I protect the confidentiality of our professional relationship and your personal information. I collect, use, and disclose information with informed consent, except where permitted or required by law. Consent to disclosure may be oral or written, depending on the circumstances, and will be documented.

Legal limits may include:

• Disclosure necessary to address a significant risk of serious harm to you or another person.
• Mandatory reports concerning a child who may need protection or other reporting obligations that apply in particular circumstances.
• Mandatory reporting concerning sexual abuse by a regulated health professional, subject to applicable legal requirements concerning client identification.
• Disclosure legally required through a court, tribunal, warrant, or other authorized legal process.
• Disclosure permitted or required for regulatory investigations, inspections, or quality assurance processes.
• Other limited circumstances permitted or required by law, including certain situations involving incapacity and an authorized representative.

These examples do not mean that every disclosure of suicidal thoughts, difficult experiences, or family concerns automatically results in a report. I consider the circumstances and applicable obligations.

Whenever reasonably possible and legally permitted, I will discuss a necessary disclosure with you before it occurs. Urgent safety circumstances or legal requirements may prevent advance discussion. I will limit disclosure to information reasonably necessary for its purpose.

Clinical records and privacy

I maintain a clinical record documenting information relevant to your care, such as contact information, relevant history, assessment information, goals, consent discussions, session notes, and significant communications.

Clinical records are stored securely in Jane App, separately from my public website and course platforms. Jane encrypts information during transmission and storage and identifies its Canadian server locations as Montréal, Quebec, and Calgary, Alberta.

Jane supports electronic health records, booking, invoicing, and receipts. Stripe may process information required for invoicing and payments. My website hosting and course providers are not provided with access to clinical notes or the contents of psychotherapy records.

Billing and appointment information can itself be sensitive health information. I limit information shared with service providers to what is reasonably necessary for their functions.

I manage records in accordance with Ontario’s Personal Health Information Protection Act, 2004 (PHIPA), applicable professional requirements, and the Personal Information Protection and Electronic Documents Act (PIPEDA), where applicable. Records are retained for applicable legal and professional retention periods and securely destroyed when appropriate. Making a file inactive does not delete it.

You may request access to your record or correction of information, subject to applicable legal exceptions. Any applicable access-related fee will be explained in advance.

If professional consultation is helpful, I will use de-identified information where reasonably possible. If identifiable information is proposed for consultation or supervision, I will explain the arrangement and obtain consent unless another lawful basis applies.

Further information is available in my website’s Privacy Policy.

Couples and family services

Before beginning couples or family therapy, we will clarify:

• Who is receiving services and who is responsible for payment.
• The goals and structure of treatment.
• How records are maintained and access requests handled.
• How information shared individually or between sessions will be managed.
• Whether individual meetings may occur within the joint treatment.

We will agree on these arrangements before proceeding. I cannot guarantee that other participants will keep information confidential. Access to one participant’s information does not automatically authorize access to another participant’s confidential information.

Session length and attendance

Appointments are available for 60 or 90 minutes, as agreed upon when booking.

Sessions run for the full booked duration: 60-minute sessions include a full hour of therapy, and 90-minute sessions include a full 90 minutes.

Sessions end at the scheduled time. If you arrive late, the session will generally end as scheduled, and the full booked fee applies.

Appointments and cancellations

Please provide at least 24 hours’ notice before your scheduled appointment if you need to cancel or reschedule.

For appointments cancelled with less than 24 hours’ notice, or missed without notice, the cancellation charge is 50% of the booked session fee:

These are missed-appointment charges, not charges for psychotherapy delivered. They may not be reimbursable by insurance or funding programs. Exceptional circumstances will be considered.

Fees and payment

My fees are:

Payment is due at the end of each session unless we agree otherwise. Any additional services or administrative charges will be discussed and agreed upon before being incurred.

Psychotherapy services that qualify for the applicable GST/HST exemption are not charged GST/HST. Different tax treatment may apply to services outside that exemption.

I will provide reasonable advance notice of fee changes and discuss their effect on your ability to continue services.

If payment becomes difficult or an account remains unpaid, please speak with me. We will discuss barriers and possible arrangements. Nonpayment will not result in automatic, immediate termination. If services must be discontinued, I will consider your clinical needs, provide reasonable notice, and make reasonable efforts to identify accessible alternatives.

Insurance and third-party funding

Please confirm that your benefits plan covers services provided by a Registered Psychotherapist, including any coverage limits or referral requirements.

Unless direct billing has been arranged, you are responsible for payment and for submitting receipts to your insurer. Reimbursement is determined by your insurer and is not guaranteed.

Where services are approved through NIHB, VQRP, or another funding program, we will confirm the approved services, funding limits, and any permitted client responsibility before treatment.

Direct billing requires a separate authorization explaining the recipient, purpose, and information to be disclosed. Signing this agreement alone does not authorize unrestricted disclosure to an insurer or funding program.

Electronic communication and social media

Email and text may be used for practical matters, such as scheduling, when we have agreed to those channels. These methods carry privacy risks, including misdirected messages, shared-device access, and unauthorized interception.

Please avoid sending detailed clinical information through ordinary email, text, or social media. We can discuss a more suitable communication method for sensitive information.

I do not provide psychotherapy through Facebook, Messenger, Instagram, or other public social media platforms. Social media messages are not a reliable way to contact me about your care.

We will agree on your communication preferences and discuss relevant risks and alternatives. Messages are not monitored continuously, and a prompt response cannot be guaranteed.

Online psychotherapy

Online appointments may take place through Jane Video or Zoom, as discussed and agreed upon before use. I take reasonable steps to select and configure technology appropriately, but no electronic system can guarantee complete privacy or uninterrupted service.

We will discuss the platform’s intended use, benefits, limitations, privacy risks, and available alternatives. Your agreement to online services does not waive my professional privacy or security obligations.

For online sessions:

• We will confirm your physical location and a telephone number where you can be reached.
• We will establish an appropriate emergency plan, including local emergency resources and, where appropriate, an emergency contact.
• Please use a private space and a device and connection you reasonably trust. Headphones may improve privacy.
• Please do not participate while driving.
• If the connection fails, we will attempt to reconnect and use our agreed backup plan, such as a telephone call.
• Please tell me before attending from another province or country so I can assess whether I am authorized and appropriately insured to provide services there.

Recording sessions or using transcription or AI tools requires prior discussion and express agreement. Consent to psychotherapy does not itself authorize recording or automated transcription.

Telephone psychotherapy

Telephone sessions are available when clinically appropriate and agreed upon in advance. We will discuss their suitability for your needs, including benefits, privacy risks, and limitations such as the absence of visual cues.

For telephone sessions:

• We will confirm your physical location and a telephone number where you can be reached.
• Please take the call in a private setting where you can speak safely and freely. Avoid speakerphone where others may overhear, and do not participate while driving.
• We will agree on who will initiate the call and what to do if the connection is interrupted.
• We will establish an appropriate emergency plan, including local resources and, where appropriate, an emergency contact.
• Please tell me before participating from another province or country so I can assess whether I am authorized and appropriately insured to provide services there.

Telephone communication carries risks, including being overheard, unauthorized access to devices, and interrupted connections. No telephone service can guarantee complete confidentiality. We will discuss alternatives if telephone sessions do not adequately support your privacy or clinical needs.

The same confidentiality, consent, fee, cancellation, and payment policies apply to telephone sessions. Any different session length or fee will be agreed upon in advance. Telephone sessions are not an emergency service.

Recording telephone sessions or using transcription or AI tools requires prior discussion and express agreement.

Urgent needs, emergencies, and crisis support

My practice does not provide continuous monitoring or emergency services. Email, text, voicemail, and website messages are not monitored continuously and should not be used to request immediate assistance.

Immediate danger or medical emergency

Call 911 or go to the nearest emergency department.

9-8-8: Suicide Crisis Helpline — Canada

If you are thinking about suicide or worried about someone else, call 988 or text 988. Support is available 24 hours a day, every day, in English and French.

Kids Help Phone — support for young people

Call 1-800-668-6868 to speak with a professional counsellor, or text CONNECT to 686868 to reach a trained volunteer crisis responder. Both services are available 24/7.

ConnexOntario — finding services

Call 1-866-531-2600 for 24/7 information and referrals to mental health, addiction, and problem-gambling services in Ontario. ConnexOntario helps locate services; it does not replace emergency care.

We will discuss resources appropriate to your location and needs as part of your care and safety planning. If you attend sessions from outside Ontario or Canada, we will identify relevant local emergency and crisis services.

Ending services and inactive files

You may end therapy at any time. You do not need to continue treatment simply because I have recommended further sessions. You are welcome to discuss concerns or preferences, and we can consider changes or other services.

If I need to discontinue services, I will explain the reasons, consider your clinical circumstances, provide reasonable notice where possible, and make reasonable efforts to support referral or transition when further treatment is wanted.

If you cancel and do not reschedule, I will make reasonable efforts to contact you. If there is no response for three weeks after the cancelled appointment, your file may be designated inactive after appropriate notice and consideration of your circumstances.

An inactive file is retained according to record-retention requirements. You may contact me to request further services, although immediate availability cannot be guaranteed. If my practice is full, we can discuss a waitlist or alternative providers.

Questions, feedback, and complaints

I welcome questions and feedback about your care. You may raise concerns with me, but you are not required to do so before contacting CRPO or another appropriate body.

Pauline O’Brien, RP

Email: paulineobrienrp@gmail.com

Phone: 905-536-8830

College of Registered Psychotherapists of Ontario

Website: https://crpo.ca

Phone: 416-479-4330 or 1-844-712-1364

Concerns about the handling of personal health information may also be directed to the Information and Privacy Commissioner of Ontario at https://www.ipc.on.ca/.

Acknowledgment and consent

By signing below, I confirm that:

• I have reviewed this agreement and had an opportunity to ask questions.
• The nature and purpose of proposed services, relevant benefits and risks, alternatives, and implications of declining treatment have been discussed with me.
• I understand the session lengths, fees, cancellation policy, privacy arrangements, and limits of confidentiality.
• I understand that consent is voluntary and ongoing and that I may refuse an intervention or withdraw consent.
• I understand that separate consent may be needed for specific services, disclosures, direct billing, electronic communication, or other activities.
• I consent to the psychotherapy services discussed and agreed upon with Pauline O’Brien.

Client name: ____________________________________

Client signature: _________________________________

Date: __________________________________________

Authorized substitute decision-maker, if applicable:

__________________________________________________

Relationship and authority to consent:

__________________________________________________

Signature: ______________________________________

Therapist signature: _______________________________

Date: __________________________________________

Communication and remote-service preferences

Complete only after discussing the relevant risks, safeguards, and alternatives. Leave any option you do not agree to unchecked.

☐ I agree to scheduling and administrative communication by email.

☐ I agree to scheduling and administrative communication by text.

☐ I consent to online psychotherapy through Jane Video.

☐ I consent to online psychotherapy through Zoom.

☐ I consent to psychotherapy by telephone after discussing its benefits, limitations, privacy risks, and alternatives.

☐ I prefer to discuss alternative communication or service arrangements.

Agreed preferences, limitations, and backup plan:

__________________________________________________

__________________________________________________