In-Take Form




Thank you for booking a visit with Core Centre! Please fill out this form before your first appointment. Thank you.

Psychological services offered at Core Centre are fee-for-service and are reimbursable through many extended health plans and are also tax deductible.
  • Personal Information:

  • Agreement

  • In order to ensure that you are informed about how we will proceed at this first meeting and subsequently, we would like you to read the statements below and sign your name at the bottom of the page to indicate that you understand them and agree.

    In seeking treatment, I understand that every effort will be made to ensure that:

    • Any counseling service offered to me will be appropriate to my needs.
    • If Dr. Ewa Antczak or any of her Associates feels that this is not the best place for me to receive therapy or other services, I will be referred to other agencies or therapists who may be more suited to me.

    Confidentiality

    • I understand that confidentiality is respected at all times. No information will be communicated directly or indirectly, to a third party without my informed and written consent.
    • Exceptions to confidentiality include the legal obligation to:
      • inform a potential victim of violence of a client’s intention to inflict harm;
      • inform the emergency contact of a client’s intention to end his/her life or inflict self-harm;
      • release a client’s file if it is subpoenaed by a court of law;
      • inform the appropriate authorities if any actual or suspected child or elder abuse arises;
      • inform the appropriate authorities if a client reports sexual abuse on the part of a health care professional.

    Financial Policy

    • Our fees are set in accordance with the guidelines put forth by the Ontario Psychological Association.
    • An hour of treatment includes 50 minutes of face-to-face contact and 10 minutes for me to document my activities.
    • Billing will also occur for services done outside the therapy hour, such as phone calls, letters and they are calculated at hourly rate for each hour.
    • All fees should be paid at the time the service is rendered. Cash or personal checks are welcome. Credit card payments are also available (3% will be added).
    • There is a 24 hour cancellation policy and I understand that I will be billed $70.00 if I do not provide adequate notice.
    If you have any questions regarding the above information, please feel free to ask.  
  • This field is for validation purposes and should be left unchanged.

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