I CONFIRM THAT:
I do not have a family or personal relationship to the Therapist or Counsellor or any other potential conflict of interest.
I understand that if I choose a Therapist or Counsellor who is not a regulated health professional they are not subject to professional discipline by the College of Physiotherapists of Ontario or any other regulatory body.
I understand that funding shall be paid only to the Therapist or Counsellor, and it shall be used only to pay for therapy or counselling for the sexual abuse that made me eligible for funding and shall not be applied directly or indirectly for any other purpose.
I understand that the maximum amount of funding payable to any Therapist or Counsellor approved under this or any other application to the College of Physiotherapists of Ontario 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 not to exceed $17,370.
I will use the other sources of funding for therapy or counselling that are available to me first.
I understand that there can be no duplicate payment for the same service. To my knowledge OHIP or any other private insurer is not covering the costs associated with the therapy or counselling I receive from the Therapist or Counsellor. If at any time, OHIP or a private insurer can pay for the therapy or counselling, I shall notify the College of Physiotherapists of Ontario.
I understand that I will need to pay for any cancellation or late fees.