Book an Appointment - Seymour Psychological Services

New Patient Form for Seymour Psychological Services in Halifax

Save time and effort at your initial consultation for psychological services at Seymour Psychological Services in Halifax by completing this required form prior to your appointment.

If you have questions, contact our office for more information.

Contract for Services

Name of Client *

Date of Birth *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Cell Phone *

Is it ok to leave voicemail messages on your cell phone? (if required) *

Is there another phone number that you'd like to add as an alternate phone? *

I hereby acknowledge that I have been informed of and /or agree to the following stipulations regarding the services I am attaining from Seymour Psychological Services Inc:

The fee is $210.00 for Individual, Couples’ and/or family Therapy -- based on the standard of 50 minutes of counseling/assessment time and 10 minutes of administration/recording time. Assessment services, requested correspondence and/or reports will be provided at an additional fee which will be discussed and agreed upon before such services are provided.
I am responsible for ascertaining whether the services I am receiving are covered by my supplemental health insurance plan; I have been provided a NSBEP Registration Number and, where relevant, have been informed of the meaning of “Candidate Register” status.
MISSED APPOINTMENTS, INSUFFICIENT CANCELLATION OR RESCHEDULING NOTICE: As a courtesy to our clients on our waiting list and to your Psychologist, our policy concerning missed or rescheduled (without sufficient notice) appointments is adhered to without exception. In signing this consent form you are agreeing to the terms outlined below. If you require clarification of any point, please discuss with your Psychologist before signing. A booked appointment is time that has been reserved exclusively for you. This time remains your financial responsibility unless you release it for use by someone else by providing:
- At least 24 hours’ notice of cancellation or rescheduling. Monday appointments must be cancelled/rescheduled by 12 noon on the previous Friday. Appointments scheduled on the first day following a holiday must be cancelled/rescheduled by 12 noon on the last business day before the holiday. 48 hours’ notice is required for appointment scheduled for 2 hours or longer.
- The cost for time missed or cancelled/rescheduled without sufficient notice rests with you. In the case of illness or inclement weather, a telephone session can be arranged for you.
- The fee for missed appointments is the same as for appointments attended. Fees for missed appointments must be paid in full to retain any further appointments in our schedule.
- *Receipts for missed appointments will indicate “Missed Appointment” and may not be covered by insurers.
LATE ARRIVALS AND EARLY DEPARTURES: Unfortunately, time lost because of the above cannot be made up. Please call our office if you are going to be late, and your Psychologist will wait for you to begin your session. Any late arrivals beyond 20 minutes without notice will be considered cancelled.

Information about Payments

I agree that fees will be charged to my credit card account for appointments missed or cancelled without sufficient notice, as described above, and hereby authorize any such charges. This authorization guarantees my future appointments will be reserved for me.*

I understand that fees for appointments missed or cancelled without sufficient notice, as described above, will be paid immediately. I realize that without immediate payment, appointments already scheduled for me will be cancelled and that my account will be forwarded to a collections agent if it remains unpaid after 30 days.

I have read, understand and agree to the terms noted above:

Write your full legal name to sign *

Date of Signature *