5-Star Rated Healing in Toronto, ON

Fertility Intake

To disclose & exchange information with your fertility treatment providers.

Fertility treatment

I am requesting your consent so that after our counselling session, I can provide a letter to your fertility doctor outlining that you have completed the counselling requirement and that you are ready to proceed with treatment.

I work under Psychologist, Dr Stephanie Bot. As an associate, Dr. Bot supervises my work and helps me guide my practice. If you ever wanted to speak to her, just let me know. She’s lovely!
Thanks for choosing me to help you along your journey.

Informed Consent Form

Fertility Intake

Emergency Contact

Please add a Contact Name & Phone Number in Case of Emergency.

Duty to Warn:

Do you agree to disclose and exchange information with your fertility treatment providers?

Inform a potential victim of violence if the client discloses an intention to inflict harm.

Inform the emergency contact if a client shows 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 in any actual or suspected child or elder abuse.

Consent to Agree *