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 Office Policy:

Please take a moment to thoroughly review this document, as it is our informed consent for services.  Maternal Health Niagara offers Social Work, Psychotherapy, and Clinical Counselling services.  

We are regulated providers with our respective colleges. The Ontario College of Social Workers and Social Service Workers regulates registered Social Workers.  The College of Registered Psychotherapists of Ontario regulates RPs and RP (Qualifying). The Canadian Counselling and Psychotherapy Association regulates Canadian Certified Counsellors (CCC) 

Professional Fees Sessions are 50 minutes and 10 minutes for case notes, for a total of 60 minutes. 

Social Worker (Schedule A)I

ndividual Therapy: $175

Couples & Family Therapy: $210 Emily Pollak, MSW, RSW; Jessica Cleeve, MSW, RSW; Randi Paxton, MSW, RSW; Tahera Vawda, MSW, RSW, Heidi Bercovici, MSW, RSW;  

Social Worker (Schedule B)

Individual Therapy: $150

Couples & Family Therapy $185

Registered Psychotherapist & RP (Qualifying) (Schedule A)

Individual Therapy: $175

Couples & Family Therapy: $210 

Lisa Marie Thompson, RP (Qualifying) 

 Registered Psychotherapist & RP (Qualifying) (Schedule B)

Individual Therapy: $150

Couples & Family Therapy $185 

Amanda Tran, RP (Qualifying) 

Canadian Certified Counsellor (CCC)

Individual Therapy: $175

Couples & Family Therapy: $210 

Lisa Marie Thompson, CCC  

MSW Students:$100/ 60 minutes for individuals*Supervised  

Fees are reviewed annually and are subject to change. 

Jurisdictions:

We can only provide services when clients are physically in Ontario. 

Payment:

• We accept credit cards and e-transfer payments.  
• Full payment is required at the end of each session.  
• Outstanding balances may result in the suspension of future sessions. 
• Your therapist will issue a receipt upon payment. 
• During exceptional circumstances, please speak with your therapist.  

Administrative Fees:

We prorate our service fee for clinical administrative tasks at 15-minute intervals. 

Records requests will be subject to the therapist's clinical fee and other applicable fees, such as printing and registered mail. 

Attendance:

• Please arrive on time for your appointment. 
• If you are running late, please email your therapist directly. 
• If you have not arrived within 10 minutes, your session will be billed as a no-show. 
• If you attend late, your therapist will charge the full session fee, and the appointment must end on time. 

Cancellation/ No-show Fees:

• We require a 24-hour cancellation notice. 
• Please email your therapist DIRECTLY to cancel your appointment. (Responding to appointment reminders goes to our client care coordinator, where your therapist will not directly receive your cancellation.)
• 
  

If you provide less than 24 hours of notice:

• 1st late cancellation- $45
• 2nd late cancellation- 50% of session fee
• Any future cancellations will incur a full fee
• No-show will be a full fee 

The therapist will charge the credit card on file per the cancellation/no-show policy. 

*Most extended benefits do not reimburse for no-shows/ late cancellations.

Booking & Appointment Reminders:

• Active clients can view their therapist's schedule on Jane. -We recommend booking your appointments at least one month in advance to ensure your preferred time is available. 
• Opting into appointment reminders via email and/or text is an option. 
• To book an appointment, a valid credit card is required. -
• You can join the waitlist if you need an appointment and your therapist is unavailable. We try to offer openings as they become available. 
• Please note that the system is live, so we cannot guarantee that the spot will stay available. 

Extended Benefits:

•  It is your responsibility to ensure your extended benefits cover the professional designation of your therapist. 
• We encourage you to verify your service coverage with your extended benefits provider. This includes checking the professional designations and the funds available to you. 
• You are responsible for any service fees that are not covered by your benefits.
• If you are utilizing direct billing, you are responsible for notifying your therapist directly if your insurance plan changes. 
• Your therapist will provide you with a receipt upon payment. You can then use this receipt to submit your claim to your extended benefits 
• Some therapists on our team can bill your extended benefits directly. 
• Please note Maternal Health Niagara offer a coordination of benefits.

For more information, please talk to our client care coordinator. 

Health-Related Services and CRA Tax Eligibility Clause

Health services provided by regulated professionals, including Registered Social Workers (RSWs), Registered Psychotherapists (RPs), and Canadian Certified Counsellors (CCCs), may qualify as eligible medical expenses under the Canada Revenue Agency (CRA) guidelines.  

Clients are advised that services rendered by these professionals, when related to the diagnosis, treatment, or prevention of a mental or physical illness, may be claimed as a medical expense tax credit on their personal income tax return, provided that the practitioner is licensed or certified by a regulatory body recognized by the province or territory in which the service is delivered.

It is the responsibility of the client to retain official receipts and consult the CRA website or a qualified tax advisor to determine the eligibility of specific expenses under the Income Tax Act. We do not provide tax advice and cannot guarantee CRA acceptance of individual claims.  

Personal Health Records/Collection & Use of Information:

Maternal Health Niagara is the Health Information Custodian (HIC). 

-Maternal Health Niagara uses Jane to keep your electronic health records. Emily Pollak owns this account. 

-Information collected includes your personal information, service dates, billing details, credit card numbers, case notes, assessments, and other clinical documents. 

-Your therapist will complete the documentation by their regulatory body and the Personal Health Information Protection Act (PHIPA). 

-Maternal Health Niagara manages and stores your health records in compliance with the relevant regulatory bodies. - Jane provides integration programs such as Stripe, E-TELUS Claims 

- Your name and appointments may be visible to the team.

 -All associates, students and contractors adhere to Maternal Health Niagara's practice policies. 

if you have concerns, please speak with your therapist or Emily Pollak, the clinic owner.  

Client Care Coordinator:

Our client care coordinator has access to your administrative records, billing information, appointment scheduling, and any information you provided during your brief consultation. She also assists with sending letters and faxes. 

Our client care coordinator maintains records in accordance with Maternal Health Niagara's office policy, including uploading emails and taking notes for client contacts. 

Third-Party Programs:

We utilize various third-party programs at Maternal Health Niagara to manage our practice, including, but not limited to, SR FAX, GoDaddy, Microsoft Office 365, Ooma, Zoom, Doxy, Psychology Today, Trello, Teksavvy and insurance provider platforms. 

-These are subject to change based on the clinic's needs. -Therapist cell phone plans. 

Contact Information:

Please ensure that your personal information remains up to date, including your address, phone number, date of birth, and emergency contact information. 

Confidentiality: 

Maternal Health Niagara prioritizes confidentiality by adhering to our established ethical guidelines and standards of practice. 

Consents to release personal information:

Your therapist requires permission to release information about you unless legal and professional obligations exist. 

You may request that your therapist share information about you. 

Your therapist will discuss the risks and benefits of sharing your personal information in these situations. 

We use a collaborative process for releasing information. -You have a right to limit the information shared about you and revoke consent. 

If you wish to withdraw consent, please notify your therapist in writing; the therapist will then document that you have withdrawn consent to release information about you. 

The clinic owner may be consulted as the HIC

Limits of Confidentiality:

At our clinic, your privacy and safety are of the utmost importance. Information you share is treated with respect and confidentiality. However, there are some important situations where Maternal Health Niagara may be required to share information, either because of legal obligations or to ensure your safety or the safety of others. 

Duty to Warn/Protect- Risk of Serious Harm

• If the client presents a clear, serious, and imminent risk of harm to themselves or an identifiable person.
• Suicide risk is present with intent, means, and a timeline
• There is a credible threat of violence or harm to another person

In these situations, Maternal Health Niagara may be required to notify:

• Police
• Emergency services
• Hospitals or mobile crisis teams
• Family members or identified potential victims (depending on risk and context)

Disclosures are limited to what is necessary and must be documented thoroughly in the client record. 

Duty to Report – Child Protection (CYFSA)

Professionals have a legal duty to report to a Children’s Aid Society (CAS) if they have reasonable grounds to suspect that a child or youth may be in need of protection. The law requires professionals to immediately report to a Children’s Aid Society (CAS)  

The duty to report applies to any child or youth under the age of 18. This includes 16- and 17-year-olds, even though they may have more autonomy in other contexts (e.g., healthcare consent). 

Child protection risks may include:

•  physical abuse, 
• threats of harm to a child, 
• emotional abuse, 
• verbal abuse,
• sexual abuse, 
• neglect, 
• severe mental health/ substance abuse
• concerns that impair the caregiver's ability to meet the child(ren's) needs, 
• capacity or judgement concerns for the caregiver that would pose a risk to the child(ren) and 
• exposure to adult conflict and domestic violence.

The duty to report includes:

- If there was historical abuse and if there is information to suggest that the offender may have access to another child (ren), which would put that child (ren) at risk of harm. -If new information arises, we must submit another report, even if a previous one has already been submitted.  

Regulatory Body Reporting Requirements: 

Social Workers are bound by law to report a colleague (another social worker or social service worker) to the Ontario College of Social Workers and Social Service Workers for professional misconduct, including having sexual relations with a client.  

Registered Psychotherapists with the College of Registered Psychotherapists of Ontario (CRPO) are required to report professional misconduct, including if they believe a client may have been or is actively experiencing sexual boundary violations by any regulated healthcare professional. 

The Canadian Certified Counsellor regulatory body, the Canadian Counselling and Psychotherapy Association, advises the following: If a client informs a counsellor of the possible unethical conduct of another counsellor or therapist, they assist the client in fully evaluating their concern and with their decision on whether or not to take action. Regarding disclosures about non-CCPA members, counsellors inform clients of their rights to file a complaint with that professional’s association and/or regulatory college. In the case of unethical conduct by another counsellor who is a member of CCPA, such action may include contacting the CCPA Ethics Committee 

– Complaints Division  Counsellors report their concerns about the unethical conduct of another 

counsellor/therapist who is a member of CCPA directly to the CCPA Ethics Committee –

 Complaints Division when they have directly observed the misconduct and they fail to achieve a satisfactory resolution of the issue with the counsellor concerned, or because the nature of the suspected violation warrants this direct action. 

If the college investigates concerns related to your therapists, your records may be subject to review. 

Emergency Situations:

If an emergency occurs during your session, your therapist will call 911 for a paramedic, fire or police and provide any pertinent health information. 

Court & Legal Involvement:

Please be advised that our clinic does not provide court-appointed services, expert testimony, or legal assessments. We do not prepare clinical reports for court use or participate in legal proceedings. 

significantly alters the purpose and dynamicsOur therapeutic services are designed to support your personal goals, mental health, and emotional well-being. Involvement in legal processes (e.g., custody disputes, court-mandated reports, forensic evaluations) fundamentally changes the purpose and dynamic of therapy, which falls outside the scope of our practice. 

If you are seeking therapy for legal or court-related purposes, please inform us as early as possible. We will provide you with appropriate referrals to qualified professionals or organizations that offer services aligned with those needs.

If your situation changes during therapy (e.g., involvement in a custody dispute or court case), we may recommend alternative services better suited to support both your clinical and legal needs. 

Safety Planning and Internal Support

In any situation involving a concern about safety or risk, the Clinical Director (or Clinic Owner) will be notified. This step ensures that your therapist receives appropriate guidance and that any potential risks are addressed in a coordinated, ethical, and clinically sound manner. 

If more than one therapist or associate is involved in your care (e.g., in couples therapy, family work, or shared-care situations), and a safety concern arises that could affect treatment:

• We may share limited and relevant information between providers to ensure coordinated and safe care
• We will inform you of this sharing whenever possible
• Only necessary information will be disclosed, and only to professionals directly involved in your care

This is consistent with Ontario privacy law (PHIPA), which allows regulated health professionals to share personal health information within the “circle of care” when it’s required for your treatment.  

Internal Confidentiality Practices

There may be times when other family members seek services at Maternal Health Niagara.  

If we are aware, we match clients with a different therapist.  

Our internal process is to denote this on the file. 

Community Confidentiality:

If you see your therapist in the community, they will not approach you to ensure your privacy. 

Your therapist will not discuss your personal information or therapeutic work outside of sessions. 

Supervision & Consultation:

Best-practice standards include utilizing consultations and supervision. 

Your therapist may provide information about your sessions for professional development. 

It is your right to withhold or withdraw consent or place conditions on the information shared about you. 

If a conflict of interest arises between the clinical supervisor and therapist, the therapist will seek supervision elsewhere. 

If you have any concerns about clinical supervision, please share them with your therapist.

Maternal Health Niagara holds internal team meetings where case discussions may occur without disclosing identifying information when appropriate. 

 Therapeutic Process:

At Maternal Health Niagara, we acknowledge that participation in our services is voluntary and respect your personal choices. 

 We believe that therapy can offer an opportunity for healing and self-discovery. However, we would like to emphasize that specific outcomes from the therapeutic process cannot be assured. 

During your initial session with your therapist, you will comprehensively discuss your strengths and areas of need while assessing your goals for therapy. You may seek to enhance your overall functioning and improve your ability to adapt to changes. With the guidance and resources provided by your therapist, you will have the opportunity to determine what strategies are most suitable for you as we prioritize self-determination in the therapeutic process. 

Numerous factors may influence your therapy journey, including the frequency of your sessions and any changing circumstances. If you find that you are not achieving your desired outcomes, your therapist may explore alternative treatment options with you, adjust your goals, consider pausing therapy, or refer you to another service provider to better meet your needs. 

During therapy, it's not uncommon to experience some increased distress as you navigate through your experiences. You may also observe changes in your feelings or behaviours during this process. If you notice any such changes, we encourage you to discuss them with your therapist, who can provide support and guidance. 

In therapy, your therapist may offer psychoeducation and recommendations, but ultimately, it's your choice to decide in your best interest. Social workers and psychotherapists do not provide diagnoses; consult your primary care provider or an appropriate medical facility for medical concerns.

Our team is dedicated to providing professional, ethical, and respectful services. If you have any concerns, we encourage you to discuss them openly and honestly with your therapist. Alternatively, you can contact our client care coordinator or the clinic owner for assistance.  

Service Discontinuation & File Closure

To ensure ethical, respectful, and effective care, your therapist may initiate file closure under the following circumstances: 

• Inactivity: If you have not attended therapy for two consecutive months, your therapist will attempt to contact you via email to offer a follow-up appointment. If we do not receive a response within a reasonable timeframe, we will assume that you no longer require services, and your file may be closed.
• Frequent Cancellations or Rescheduling: If appointments are repeatedly cancelled or changed without sufficient notice or explanation, and this affects the continuity or effectiveness of therapy, we may discuss whether continuing care is appropriate. This could result in service discontinuation and file closure.

Other situations where file closure may be necessary include:

• The therapeutic relationship is no longer effective or appropriate
• Legal, ethical, or professional boundaries are compromised
• Abusive, aggressive, or threatening behaviour toward staff or therapists
• Your needs require services beyond the scope of our clinic or the therapist’s expertise

If your file is closed, you may be offered referrals or alternative supports, where appropriate. 

You are always welcome to reach out in the future if you'd like to resume services, pending availability. 

Returning to Services After File Closure:

If you wish to return to therapy after your file has been closed, please contact our Client Care Coordinator to discuss the next steps. At that time, we will:

• Review current availability within our clinical team
• Determine whether services can be reinitiated based on your needs and the therapist's capacity
• Do our best to honour requests to reconnect with a previous therapist, though please note that therapist availability can change and may be limited.

We are committed to supporting a smooth return to care whenever possible and will offer appropriate referrals or alternative options if a match within our clinic is not currently available. 

Scope of Practice

Each therapist at our clinic brings a unique set of professional skills and areas of expertise.  If your clinical needs fall outside your therapist’s scope of practice or their specific areas of competence, your therapist will discuss this with you openly and work with you to create an appropriate plan moving forward. This may include:

• Seeking consultation with other professionals
• Transferring your care to another therapist within the clinic
• Providing referrals to external providers better suited to your needs
• Closing your file, if appropriate and in alignment with ethical standards

Our priority is to ensure that you receive the most effective, ethical, and appropriate care for your unique situation.  

Therapeutic Approach & Open Door Policy:

Maternal Health Niagara recognizes that a strong therapeutic alliance is central to effective treatment. 

We uphold an open-door policy that encourages clients to communicate openly if they feel their therapist’s approach does not align with their needs or preferences.

• Clients are invited to contact the Client Care Coordinator at any time to discuss concerns regarding their therapeutic approach or to request adjustments.
• The Client Care team will respond promptly, offering support and exploring options, including referral to another therapist within the clinic or alternative therapeutic modalities.
• All communications are handled with confidentiality, respect, and sensitivity to the client’s well-being and preferences.
• Our goal is to ensure every client receives care that is both clinically appropriate and personally meaningful.

Contact:Clients may reach the Client Care Coordinator via email at hello@maternalniagara.ca.  

Communication:

• Our therapists strive to respond to phone calls and emails within their regular business hours to provide timely support.
• Response times may vary depending on each therapist’s availability within Maternal Health Niagara.
• When contacting you by phone, therapists typically call from a private number. 
• Therapists primarily use personal cell phones for client communication, while the Client Care Coordinator uses a VOIP phone system. 
• Please note that VoIP and cell phone communications are less secure than traditional landline communications.
• If you have any concerns about communication methods or privacy, please discuss them directly with your therapist or the Client Care Coordinator. We are committed to addressing your concerns and maintaining your confidentiality.

Texting & Email Communication:

• Therapists may use texting and email to communicate with you regarding appointment scheduling, changes, or other administrative matters.
• Please be aware that emails, text messages, cell phones, and social media platforms are not secure forms of communication and may carry risks to your privacy.
• Any communication exchanged through these channels may be documented and become part of your clinical record in accordance with professional standards and regulatory requirements.

Virtual Therapy

• For virtual therapy sessions, please ensure you are in a private, comfortable, and safe space where you can speak openly and without interruptions.
• To protect your confidentiality, please make sure there are no monitors, recording devices, or others who can overhear your session in your space.
• If you have any concerns about your privacy or safety during virtual sessions, please discuss them directly with your therapist.
• If you join a virtual session and the therapist’s virtual “door” appears locked or you experience a delay, please wait patiently; your therapist will join and greet you shortly.
• Please note we are unable to provide therapy if you are driving a vehicle due to safety reasons.

Office Location:

245 Pelham Road, Unit 204A, St. Catharines 

Illness:

• If you are ill and need to cancel your appointment, please get in touch with your therapist directly. 
• Your therapist may also need to cancel at other times. We must extend compassion during these times. 
• Please do not attend the office if you are unwell; we can shift to a virtual session or reschedule for another time. 

Client Reviews & Feedback

• Our clinic uses the Jane App, which allows clients to provide a private review or rating after their appointments.
• These reviews are confidential and used solely for the purpose of evaluating and improving clinical services.
• Providing feedback through the Jane App is entirely voluntary.
• It is considered unethical for Registered Social Workers or Psychotherapists to request or encourage clients to write reviews or testimonials.
• Please note that we do not respond to reviews on public websites. If you have any concerns or feedback, we encourage you to contact us directly.

Social Media Policy:

• Social media platforms are intended for public networking and sharing information, and content shared there is generally not private.
• Therapists will never share any information about their clients on social media.
• Please be aware that your therapist may see posts or comments you make if you are active in the same groups or pages.
• If you comment on Maternal Health Niagara’s social media pages, please note that we do not respond to comments publicly.
• For professional boundaries and privacy, our therapists and team members cannot accept personal friend or connection requests from clients on social media platforms.

Crisis Services:

Maternal Health Niagara does not provide crisis or emergency services. 

If you are experiencing an imminent risk of harm to yourself or others, please call 911 immediately or go to your nearest Emergency Room for urgent support.  

Ontario Crisis Services:

Provincial Abuse Support Lines

Assaulted Women's Helpline 1 (866) 863-0511

Canada Suicide Prevention Service 1 (833) 456-4566

Kids Help Line- 1 (800) 668-6868 or text CONNECT to 686868 

Local Niagara Services:

Crisis Outreach and Support Team (COAST) Niagara: 1(866) 550-5205 ext. 1

Niagara Region Sexual Assault Centre (CARSA): 1(905) 682-4584

Pathstone Mental Health Services: 1(800) 263-4944

Gillians Place 1(905) 684-8331

Niagara Children and Family Services 1(888) 937-7731 

Conflict Resolution Process

Open Communication 

• Clients are encouraged to raise concerns      or conflicts directly with the practitioner involved as soon as possible. 
• If the client is uncomfortable doing so,      concerns may be directed to the group practice manager or designated      contact person. 
• Our team will listen openly and      respectfully, aiming to understand the client’s perspective and to resolve      the issue collaboratively. 

Resolution 

• Efforts will be made to resolve concerns      informally through discussion, clarification, or adjustments to services. 

We prioritize maintaining trust and a positive therapeutic relationship  

Contact information:

Client Care Coordinator: hello@maternalniagara.ca 

Emily Pollak, MSW, RSW, Clinical Director & Owner- Admin@maternalniagara.ca 

Regulatory Bodies Contact Information

Ontario College of Social Workers and Social Service Workers (OCSWSSW)
Website: www.ocswssw.org
Phone: 1-877-828-9380
 

College of Registered Psychotherapists of Ontario (CRPO)
Website: www.crpo.ca
Phone: 1-844-712-1364
 

Canadian Certified Counsellors (CCPA)
Website: www.ccpa-accp.ca
Phone: 1-877-765-5565