PSYCHOTHERAPY
GERIATRIC CARE MANAGEMENT AND CAREGIVING CONSULTING
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Consent
The following Terms of Use (“Terms”) constitute a legally binding agreement between you and ERG regarding your use of the Services, defined below. I represent that I am of legal age to agree to these Terms. If you do not agree to all of the Terms, then ERG is unwilling to provide any services to you. I, the undersigned,
Name:
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Address:
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Street Address
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State / Province / Region
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Afghanistan
Albania
Algeria
American Samoa
Andorra
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Anguilla
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Australia
Austria
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Taiwan
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Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Telephone:
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Alternate Telephone
Email
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authorize Stephanie Erickson, operating under the corporation Erickson Resource Group Inc. (hereinafter collectively referred to as “ERG”) member of the OTSTCFQ (ER/05/290), to provide me with caregiving consultation services at a distance using information and communications technologies, such as interactive messaging, audio and video technology (hereinafter, the “Services”), each such interaction being a “Consultation”. I understand that use of the Services and any Consultation is at my sole risk.
Payment and Fees
I, the undersigned, agree to pay the fee of $140 per 60 minutes , in Canadian funds, (taxes non-applicable) for the Services which include, but are not limited, to the following activities: *on-line/telephone/video conferencing for family caregiving psychosocial consultation; on-line/telephone/video conferencing for general wellbeing psychosocial consultation - to provide ERG with valid credit card information to be used as the form of payment. I accept that my credit card will be charged when I book a Consultation and that ERG is not responsible for exchange rate fluctuations or for any processing fees charged by your payment provider or financial institution. The Consultation shall last 60 minutes, unless the Consultation has been extended in accordance with these Terms of Use. ERG will provide you with a verbal warning when the session is 10 minutes from completion. If the Consultation is eligible for an insurance receipt, we will provide you with one. Any additional Services provided to you will be charged to your credit card once such Services have been rendered.
Limitations
Electronic social work services, such as the Services, are convenient and promote access to care. However, there are certain limitations and potential risks associated with such Services, including, but not limited to, the following: There are certain risks associated with disclosing confidential information on the Internet, social media sites, text-messaging sites and any videoconferencing sites. Although ERG will use reasonable efforts to protect your personal information and personal health information, there is no guarantee against data breaches, which may result in the unauthorized collection, use and/or disclosure of your personal information; The provision of the Services is dependent on broadband infrastructure and as such, the Consultations are susceptible to interruptions, degradation or loss of connection; Although ERG is committed to providing quality care and aims to meet the anticipated benefits of such care, no results or outcomes can be guaranteed or assured; ERG reserves the right to suspend services without liability if you commit a breach of any of these Terms. Consultations are not intended to replace your existing healthcare providers, such as your family doctor; and Consultations are not intended for medical emergencies. If you have a medical emergency, call 911 or you must contact emergency services in your area or go to the nearest hospital or healthcare center. The Services are being provided to you in order to assist and support you in your role as a caregiver to another individual (the “Third Party”). The Services provided to you are based on information received by you, without further investigation, and as such we are not responsible for any incorrect interpretation of the Third Party’s condition. Further, we are not responsible to the Third Party for any care you provide as a result of the Services. The Services do not replace the need for the Third Party to receive local medical care and evaluation.
User Accounts
In order to book a Consultation, you will be required to provide us with certain information, such as your full name, date of birth, email address, phone number, and mailing address. You will also be required to provide us with payment and banking information to facilitate payments to ERG. You agree that you will provide accurate, current and complete information about yourself and promptly update all information at any time via email to infostepherickson@gmail.com in order to ensure that your file with us is accurate, current and complete. You are solely responsible for ensuring that you use the Services in accordance with these Terms of Use in the jurisdiction where you are located at the time of a Consultation and as permitted by that jurisdiction’s law or regulation. You may access and use the Services through a mobile device or via a web browser. You are solely responsible for any software requirements and for any data charges and fees associated with accessing and using the Services.
Account Termination and Cancellation
You have the right to terminate your use of the Services at any time via email to infostepherickson@gmail.com provided that (i) any disputes in which you have been involved have been satisfactorily resolved; (ii) you have met all outstanding payment obligations associated with your use of the Services; and (iii) you have completed any other obligation(s) associated with your use of the Services. We reserve the right to preserve, retain or delete your information, including personal information, in accordance with any applicable laws and regulations. You may cancel any scheduled Consultation with twenty-four-hour notice without incurring any cancellation fees. In such a case, since payment is made at the time of booking, the cost of the Consultation will be reimbursed to you. Any late cancellation or missed appointment will be noted in your file and will not result in reimbursement.
Mandated Reporting
Although the confidentiality of the Consultations is of utmost important to us, ERG is a mandated reporter and as such is required to report acts of abuse against persons under curatorship, tutorship, or homologated protection mandate, regardless of their place of residence.
Connectivity
In the event that a Consultation is interrupted due to a loss of connection or other technological failure or malfunction, ERG will attempt to reconnect with you by using the predetermined method of communication for that Consultation. Please check the box that you wish for Ms. Erickson to contact you during your allotted time and an unavoidable technical problem. Please indicate the related phone number or email to use.
Email
Text
Cell Phone
Land line phone
Back Up Communication Method
*
Email
Text
Cell Phone
Land line phone
If such reconnection fails, ERG will attempt to use the alternate method of communication you provided in these Terms of Use. Should that reconnection attempt fail or should the time of the disconnection be greater than 20 minutes, ERG will contact you to schedule a new Consultation in order to make up the time lost. Except for as described above, we shall not be liable for delays, interruptions, service failures, or other problems inherent in use of the internet, electronic communications, telecommunications networks or other systems or networks outside our reasonable control. By signing these Terms of Use, I certify: That I have read these Terms of Use; That I fully understand the contents of these Terms of Use including the risks and benefits thereof; and That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction. That I agree that these Terms be drafted in the English language only. J’accepte que la présente soit rédigé en anglais.
Consent
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I agree to the privacy policy.
Date
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