Counsellor or Therapist Attestation

You have been provided access to this form as a patient you are seeing or with whom you are about to initiate counselling or therapy has indicated that you will be treating them. This patient has been granted funding for therapy and counselling from 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. These attestations contained on this form are required as a part of the funding program.

INSTRUCTIONS

This form must be completed by the Counsellor or Therapist. It may not be completed by a patient being funded for counselling or therapy.

A. Counsellor/Therapist Information

Please provide the following information.

Counsellor/Therapist Name

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

Counsellor/Therapist Address

Please provide the street number, street name and unit or suite number of the location where you are providing services.

City, Town, Community

Please provide the name of the city, town or community in which you are providing services.

Province or Territory

Please select the Province or Territory in which you are providing services.

Postal Code

Please provide the postal code for the address where you are providing services.

Business Telephone

Please provide the telephone number for your practice location.

Please provide an email address where the College may communicate with your or send you information.

Are you a Regulated Health Professional?

Yes

B. PATIENT INFORMATION

Please provide the following information about the patient.

Patient Name

Please provide the first (given) and last (family) name of the patient that you are treating under this program.

Patient Funding

Besides funding from the College of Naturopaths of Ontario, please list the name of each insurance provider that will fund the costs of these treatments and the amounts they will cover.

C. ATTESTATIONS

Please review each of the following statements and indicate whether you agree with that statement.

2. I am providing or proposing to provide therapy or counselling to the patient I have named above in relation to practitioner sexual abuse.

Agree

I do not agree

3. I have not at any time or in any jurisdiction been found guilty of professional misconduct of a sexual nature or been found liable, criminally or civilly, for an act of a sexual nature.

I agree

I do not agree

4. The funds being provided by the College of Naturopaths of Ontario are being used to cover the costs of therapeutic and/or counselling sessions.

I agree

I do not agree

5. I do not have any family relationship to the applicant or any other potential conflict of interest.

I agree

I do not agree

6. No other sources of funding for the therapy or counselling are available to the applicant those that I have listed above.

I agree

I do not agree

7. If at any time other sources of funding become available to the applicant, I shall notify the College and, where appropriate, cease submitting claims to the College. I understand that there can be no duplicate payment for the same service

I agree

I do not agree

8. I understand that the maximum amount of funding payable to any therapist/counselor 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.

I agree

I do not agree

9. I understand to keep confidential all information obtained through the application for funding process, including, if funding is granted, the fact that funding has been granted and the reasons given by the Patient Relations Committee for granting the funding, and to refrain from using that information for any collateral or ulterior purpose.

I agree

I do not agree

D. SIGNATURE

I voluntarily sign this form and affix my digital 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.

I voluntarily sign this form and affix my digital signature.

E. 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

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