Application for Funding for Therapy and Counselling

A. APPLICANT INFORMATION

Please provide the following information about you as the applicant seeking funding for therapy or counselling from the College.

Name*

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

Mailing Address*

Please provide the street number, street name and unit or suite number where the College may send correspondence to you.

City, Town, Community*

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

Province or Territory*

Please select the province or territory in your mailing address.

Select

Postal Code*

Please provide the postal code for your mailing address.

Telephone Number*

Please provide a telephone number where you may be reached during regular business hours.

Phone

Email*

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

B. NATUROPATH INFORMATION

Please provide the following information about the Naturopathic Doctor against whom allegations of sexual abuse have been made.

Name of Naturopathic Doctor

Please provide the full name of the Naturopathic Doctor against whom the allegations have been made.

Address

Please provide the street number, street name and unit or suite number of the location where the Naturopathic Doctor is providing services.

City, Town, Community

Please provide the name of the city, town or community in which the Naturopathic Doctor is providing services.

Province or Territory

Please select the Province or Territory in which the Naturopathic Doctor is providing services.

Select

Postal Code

Please provide the postal code for the address where the Naturopathic Doctor is providing services.

Registration Number

Please provide the registration number, if known, for the Naturopathic Doctor.

C. RELATED INFORMATION

Complaint or CEO (Registrar's) Investigation

Has a complaint about the allegations of that you were sexually abused by the Naturopathic Doctor while you were a patient been filed or has a CEO's (Registrar's) Invesigation be initiated?

Yes

No

Unsure

COUNSELLOR/THERAPIST INFORMATION

Please provide the following information about the Counsellor or Therapist who is treating you or who you intend to see for treatment.

Name of Counsellor/Therapist

Please provide the first (given) and last (family) name of the Counsellor or Therapist you are seeing or intending to see.

Therapist Address

Please provide the street number, street name and unit or suite number of the location where the Counsellor or Therapist is providing services.

City, Town or Community

Please provide the name of the city, town or community in which the Counsellor or Therapist is providing services.

Province or Territory

Please select the province or territory in which the Counsellor or Therapist is providing services.

Select

Postal Code

Please provide the postal code for the address where the Counsellor or Therapist is providing services.

Telephone Number

Please provide a telephone number for the Counsellor or Therapist.

Phone

Email

Please provide an email address for the Counsellor or Therapist.

Is the Counsellor or Therapist a Regulated Health Professional?

Yes

No

Please indicate with which regulatory authority the Counsellor or Therapist is registered.

College of Physicians and Surgeons of Ontario

College of Psychologists of Ontario

College of Registered Psychotherapists of Ontario

Are the services of this Counsellor or Therapist covered by the provincial health plan (OHIP in Ontario) or by another insurer (private insurance)?

Yes

No

Have you already had therapy or counselling for the sexual abuse that may have occurred in this matter?

Yes

No

E. DECLARATIONS AND SIGNATURE

Please review each of the following declarations and the signature you are being asked to provide carefully.

Declaration 1.

I am hereby applying for funding for therapy or counselling under the program established by the College of Naturopaths of Ontario pursuant to section 85.7 of the Health Professions Procedural Code of the Regulated Health Professions Act, 1991.

Agree

Do not agree

Declaration 2.

I understand and agree that the Regulated Health Professions Act, 1991 requires me to undertake to keep confidential all information obtained through the application for funding process. This includes, if funding is granted, the fact that funding has been granted and the reasons given by the Patient Relations Committee for granting the funding. I further understand that I will not use this information for any collateral or ulterior purpose. This undertaking does not restrict my right to use, as I see fit, any information I already have about the events leading up to this application.

Agree

Do not agree

Declaration 3.

I understand and agree that a decision by the Patient Relations Committee that I am eligible for funding does not constitute a finding of guilt against the above-named Naturopathic Doctor and shall not be considered by any other committee of the College dealing with them.

Agree

Do not agree

Declaration 4.

I agree to allow the College of Naturopaths of Ontario to contact the above named therapist/counsellor, as necessary to process this application for funding.

Agree

Do not agree

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.

I voluntarily sign this form and affix my digital signature.

F. 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.

Send me a copy of my responses