Patient Attestation

You have been provided access to this form as a patient whose application for funding for counselling or therapy as a result of sexual abuse by a Naturopathic Doctor has been approved by the Patient Relations Committee of the College of Naturopaths of Ontario.


The Patient Relations Committee follows the provisions of the Regulated Health Professions Act, 1991 (RHPA) which direct the College in administering the funding program. The attestations contained on this form are required as a part of the funding program.

A. PATIENT INFORMATION

Please provide the following information.

Please provide your first (given) and last (family) name.

Please provide the street number, street name and unit or suite number of your mailing address.

Please provide the city, town or community in your mailing address.

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Please provide the postal code in your mailing address.

Please provide a telephone number where the College can reach you during regular business hours.

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Please provide an email address to which the College may send you communication or information.

B. COUNSELLOR/THERAPIST INFORMATION

Please provide the following information about the counsellor or therapist you are or will be using for treatment.

Please provide the first (given) and last (family) name of the counsellor or therapist that is or will be providing you treatment.

Please provide the municipality in which the counsellor or therapist that is or will be providing your treatment is located.

C. FUNDING INFORMATION

Please provide information about any additional funding available to you.

Please list any and all insurance or funding sources available to you for your treatment, including the amount available from each.

D. ATTESTATIONS

Please review each of the following attestations carefully before indicating whether you agree or do not agree.

1. I do not have a family relationship with the counsellor or therapist identified in Part B above nor do I have any other potential conflict of interest with them.*
2. I understand that if I choose a therapist/counselor who is not a member of a regulated health profession, the therapist/counsellor is not subject to professional discipline by the College of Naturopaths of Ontario or any other regulatory body.*
3. I understand that funding will be paid only the therapist/counsellor, and that it will be used only to pay for therapy or counselling for the sexual abuse that made me eligible for the funding and shall not be applied directly or indirectly for any other purpose.*
4. I understand that the maximum amount of funding payable to any therapist/counselor approved under this or any other application to the College is the amount that the Ontario Health Insurance Plan (OHIP) would pay for 200 half-hour sessions of individual out-patient psychotherapy with a psychiatrist.*
5. I will use the other sources of funding for therapy or counselling available to me first, including OHIP and the funding sources identified in Part C above.*
6. If at any time other sources of funding become available to me, I shall notify the College.*
7. I understand that there can be no duplicate payment for the same service.*
8. I understand that the College of Naturopaths of Ontario will not pay for any late or missed appointments.*

E. SIGNATURE

Signature


By checking the box below, you are affixing a signature to this form and indicating that this form and the information contained herein is bound directly to you.

COPY OF SUBMISSION

Below is a check box to enable you to receive a copy of your submission. It is highly recommended that you check this box and enter your e-mail address. This will enable the on-line system to send you a copy of the information that you have provided to the College.

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