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Clients who are scheduled to see Dr. Thibodeau should complete this form. Only complete this form if Dr. Thibodeau has already agreed to see you. If you’re interested in services from Dr. Thibodeau and have not yet spoken to him you can email him at mthibodeau@mikethibodeau.ca

Please complete this form only once. It should take less than 10 minutes to complete. If you’re having trouble with the form please contact Dr. Thibodeau. Information submitted into this form is confidential and secure. Only Dr. Thibodeau is able to access the data you submit. If you have privacy concerns please contact Dr. Thibodeau at mthibodeau@mikethibodeau.ca.

This form has three parts:

Consent form (on this page)– This form will describe how your payment information will be used, privacy and confidentiality, the cancellation policy, and the nature of the services you will receive. You must agree to this information before proceeding.
Information questionnaire (on page 2) – You will need to submit information about yourself such as basic demographic information (e.g., age, address) and mental health history. Submitting this information now will allow a faster transition to treatment.
Payment information (on page 3)– You will need so submit payment information. You can read more about this below.

Consent form

Payment information and cancellation policy

Dr. Thibodeau often has a waitlist. He maintains a cancellation policy to ensure he can see clients consistently, otherwise he would see fewer clients in a day and have a longer waitlist. His cancellation policy is straightforward: You will be billed for a scheduled session if you cancel the appointment within 24 hours of that appointment. If you cancel earlier than 24 hours before an appointment, you will not be billed.

Please note that you will be required to submit credit card information in the following forms. Dr. Thibodeau collects this information to seamlessly process payments for his services and allows him to bill for sessions remotely (e.g., if doing sessions over the phone). You will only ever be billed after an appointment with Dr. Thibodeau or if you cancel within 24 hours of a scheduled appointment with Dr. Thibodeau. Please contact Dr. Thibodeau directly by email if you have any concerns.

Individuals with health insurance can often be reimbursed for the cost of sessions with Dr. Thibodeau. You can coordinate with your health insurance provider to seek reimbursement and to determine the limits of your coverage. Note that Dr. Thibodeau does not coordinate directly with insurance companies, but will provide you with receipts to provide to your insurer.

Nature of the services

You will be seen for psychological services in private practice by Dr. Michel A. Thibodeau, psychologist registered with the College of Psychologists of Ontario. These sessions may take place remotely or in person. Dr. Thibodeau will perform a psychological assessment to identify your concerns and to form a treatment plan. He will ask several questions about you and your concerns and keep a record of your sessions together to ensure the best care. You may terminate services at any time.

Privacy

Any information shared with Dr. Thibodeau verbally or in writing is confidential and will not be shared with anyone without your consent. There are a few important exceptions to this and circumstances in which Dr. Thibodeau must break confidentiality:

If Dr. Thibodeau believes you are an imminent danger to yourself or to others, he will contact authorities who can intervene to help prevent harm to you or others.
If Dr. Thibodeau believes that a child is at risk of harm, abuse, or neglect, he will contact the Children’s Aid Society to report this information.
If Dr. Thibodeau learns that you have been sexually or physically abused by another registered health provider (e.g., physician, psychologist, nurse), he will contact the health provider’s regulatory body to report this provider. He will not give out your name if you do not want him to.
If Dr. Thibodeau is subpoenaed by a court of law he is required to release his records or to testify.
Dr. Thibodeau’s files may be accessed by the College of Psychologists of Ontario for the purposes of quality assurance. The College of Psychologists of Ontario is bound by strict rules of confidentiality.
If Dr. Thibodeau learns that a resident of a Long Term Care Facility or Retirement Home is being harmed or is at risk of being harmed, he must contact the Ontario Ministry of Health and Long-Term Care or the Retirement Homes Regulatory Authority.

Dr. Thibodeau may at times speak to your other healthcare providers (e.g., family doctor, psychiatrist, social worker) about your concerns in order to coordinate quality care. Please inform Dr. Thibodeau if you do not want him to speak to your healthcare professionals.

Clients who use health insurance coverage should also be aware that insurance companies may ask Dr. Thibodeau to confirm details about the appointments (e.g., frequency, cost, number of sessions, location). Please inform Dr. Thibodeau if you do not wish for him to discuss matters with insurance companies.

You may contact Dr. Thibodeau at mthibodeau@mikethibodeau.ca prior to signing this form if you have any questions or concerns.

Please print or save a copy of this form for your records

I consent and write my name in the box below to indicate that I’ve read this consent form and agree to the terms *

Signature

Information questionnaire

First Name *

Last Name *

Full address *

Date of birth *

What is your phone number, with area code? *

What is your email? *

Like most forms of communication, email entails an element of risk. An email can be
inadvertently sent to the wrong recipient, for example, by mistyping an email address or
using the autocomplete feature. Email is often accessed on portable devices, such as
smart phones, tablets and laptops, which are vulnerable to theft and loss. Email may also be vulnerable to interception and hacking by unauthorized third parties.

Do you want Dr. Thibodeau to contact you by email to discuss simple matters such as billing or scheduling? *

Yes No

Dr. Thibodeau generally does not discuss clinical matters at length by email; however, you may agree to correspond by email in order to discuss brief clinical issues such as progress with homework or potential resources. Do you consent to corresponding by email with Dr. Thibodeau about clinical issues relating to your mental health concerns? *

Yes No

What is the name of a person we can contact in case of an emergency? *

What is the phone number of your emergency contact? *

What is the name of your family doctor (if you have one)?

What is your family doctor’s phone number?

What is the name of the practice or hospital that your family doctor works at? Or, what is the address?

What is your gender?

Man

Woman

Genderless/non-comforming

Transgender

Prefer not to say

Other

What is your relationship status?

Single, never married

Married or domestic partnership

In a relationship but not cohabitating

Widowed

Divorced

Separated

Other

Who do you live with?

Alone

With parent(s)

With romantic partner(s)

With your child or children

With roomate(s)

Other

What is your highest level of education?

Did not complete high school

High school diploma

Some college credit, no degree

Trade/technical/vocational training

College diploma

Bachelor degree

Master degree

Professional degree

Doctorate degree

Please select your employment status

What do you do for work? Or, what have you done for work previously if you’re currently unemployed?

Please indicate any existing and significant health conditions you may have.

Please indicate below any mental health diagnoses you have been assigned in your lifetime (e.g., depression, alcoholism, generalized anxiety disorder). Diagnoses are usually communicated by a physician or psychologist. (Write N/A if this does not apply to you)

Please list any medications you are taking. Also include the dosages if these medications are for your mental health.

Please enter your height in feet and inches (e.g., 5’6

Please enter your weight in pounds

How many alcoholic drinks do you consume in a typical day?

How many caffeinated drinks, such as coffee, caffeinated tea, or energy drinks, do you consume in a day?

How many cigarettes do you consume in a typical day?

How often do you consume cannabis products?

What type of psychotherapy have you done before?

I have never done psychotherapy before

Cognitive behaviour therapy

Supportive

Psychodynamic or psychoanalysis

I don’t know what kind of therapy it was

Other

How did you hear about Dr. Thibodeau?

Search engine

Recommendation by a healthcare provider

Heard about him from someone I know

Other

Do you have children?

Yes No

Payment information

Please enter your credit card information in the secure form below. Dr. Thibodeau will be able to use your credit card information to bill for all subsequent sessions. You will not be required to bring payment information to future sessions. You will not be billed now

Name on credit card:

Credit card number (NO SPACES)

Credit card expiration date:

Credit Card CVC (3 or 4 digit security number on your card)