Consent Form

Fill out this form only after you have spoken to

Dr. Regev*

Michal Regev, Ph.D., R. Psych., RMFT

Dr. Michal Regev

Registered Psychologist; Registered Marriage & Family Therapist

#424-5525 West Boulevard

Vancouver, B.C. V6M 3W6

Telephone: 604-671-7356

*Requiered

Instructions for telephone messages from this office to your home, work or cell number

Emergency Contact:

Do you wish for me to consult with your physician regarding your health care if needed?

Current medications (Write None if you don't take any meds) *

Previous / Current counselling

Please select the answer that is the most accurate for you *

1. I drink alcohol

CONFIDENTIALITY REQUIREMENTS & LIMITATIONS:

According to professional ethical guidelines the personal information you discuss in counselling sessions is confidential. No information will be released without your written authorization. However, there are situations in which I am legally required to disregard confidentiality. Specifically, if you reveal information that indicates a clear and immediate physical danger to yourself or others, or the abuse of a child, or if you are driving after being warned of having a medical condition that makes it dangerous for you to operate a motor vehicle, I am obliged to contact appropriate authorities. I am also required to release records if subpoenaed by a court order.

Are you currently receiving treatment from any other psychologist, counsellor, social worker or psychiatrist?

Were you referred to Dr. Regev?

Dr. Regev has my permission to inform the referring party of my attendance at this appointment.

In case you are receiving online therapy from Dr. Regev, you understand that Dr. Regev will continue to keep every detail of the sessions confidential, except for the above-mentioned reasons. For your own protection, please use a secured wi-fi network. Dr. Regev will be using a secured network only and will not record any part of the sessions.

CLIENT RESPONSIBILITIES:

Sessions are based on the standard fifty minutes of counselling and ten minutes administration time. Payment for services is required before the beginning of each appointment. Please e-transfer payment to mregev@shaw.ca. Dr. Regev will provide a receipt upon payment. Cancellations or requests to re-schedule appointments require a forty-eight (48) hour notice to avoid hourly costs.

I hereby accept services from Dr. Regev under the terms and conditions that have been reviewed with me. I accept personal responsibility for missed appointments and any billings not payable by third party coverage.