Version Private Pay 2020-04-01 For appointments on or after April 1, 2020
Gorsky Consulting & Management Services Inc. Operating as Mills Gosse Psychology
PSYCHOLOGICAL, COUNSELLING, ASSESSMENT, EDUCATIONAL, & VOCATIONAL SERVICES
JON MILLS, Psy.D., Ph.D., C.Psych., ABPP
Chief Psychologist
SCOTT GOSSE, M.A., C.Psych.
Clinical Manager
AGREEMENT OF INFORMED CONSENT
______________________________
I. Clinical Services Offered
Comprehensive assessments and treatment of adults, couples, adolescents, and children who present with a wide range of
psychological and emotional problems. Services range from individual psychotherapy, marital/couples therapy, and family therapy
to psychological assessments, testing, and diagnosis.
II. Assurance of Confidentiality
All psychological services constitute a professional relationship and is bound by client-therapist privilege. All efforts are made to
protect the client and avoid undue invasion of privacy. All information obtained or disclosed in an assessment or therapy is strictly
confidential and will not be revealed to any other persons without the client’s authorized consent or the consent obtained by the
client’s legal representative except in those unusual circumstances in which not doing so would result in clear danger to the client
or to others, or unless mandated by a court order or law. All staff or associates of Mills Gosse Psychology are supervised by Dr.
Jon Mills and Scott Gosse, Clinical Manager. In the event that the client wishes to speak to Dr. Mills or Mr. Gosse about any staff’s
professional conduct, the client may contact them directly at 905-686-7184. Otherwise, staff work autonomously in their therapeutic
capacities and are regarded as a respected professional who is entrusted to provide clients with the best psychological care. Because
your privacy protection is a priority for us, Mills Gosse Psychology are in full compliance with the Personal Health Information
Protection Act (PHIPA) and the Personal Information Protection & Electronic Documents Act (PIPEDA). A complete review of
our privacy policy is listed on our company website.
III. Fees
Fees for professional services are charged based on income, feasibility, and level of insurance coverage which is individually
arranged with each client. There is no OHIP coverage for psychology services in Ontario, only for medical conditions. Therefore,
you will need to carefully check with your insurance provider to determine the type, degree, amount, and duration of psychological
coverage you have under your plan and the specific procedures involved. Mills Gosse Psychology is not responsible if your insurer
denies your claim. Payment for services, if paid by cash, is due at the time of booking unless arranged differently. If payment is
made via credit card, the client’s card number and information will be held on file and used to bill via the telephone within 24 hours
of the day of the appointment. A receipt will be issued at the time of each appointment. In the event that reports or letters to third
parties or testimony is requested in a court of law, the client is responsible to pay the hourly rate for all aspects of professional time.
In the event that a client refuses to pay his or her bill, the account may be turned over to a collection agency and the client will be
charged an additional $300 administration fee. In order to maximize the effectiveness of therapy, clients should not cancel their
appointment times except in the case of an emergency. Session fees will be charged for missed or canceled appointments less than
24 hours in advance. If a client customarily pays by credit card, their account will be charged for no shows or late cancelations and
a receipt will be issued to them at their next appointment.
IV. Consent
I have read and understood the information described above and hereby request to receive clinical services at the mutually agreed
upon rate of $_____________ per hour or $__________ if the clinical service is an assessment.
Client’s/Parent’s Signature:______________________________________________ Date: ____________________________
Staff Signature: _______________________________________________________ Date: _____________________________
