Consent for Psychotherapeutic Treatment Services

Thank you for choosing Unleash Synergy and congratulations on taking this important step toward change! We kindly ask that you carefully review this vital document, as it provides essential details about our professional services and policies. Please kindly read through and confirm your review of this information by checking the checkbox at the end of this document.

Therapeutic Relationship

The therapeutic relationship is unique in that it combines highly personal elements with a contractual agreement. Therefore, it is crucial for us to establish a clear understanding of how our relationship will function and what each of us can anticipate. This consent form will establish a structured framework for our collaborative work. Please feel free to discuss any aspect of this with me.

The Therapeutic Process

Your decision to seek therapy reflects a positive step toward self-improvement. Psychotherapy and/or counseling represent a joint effort between you and your psychotherapist/counsellor. Your active engagement in the therapeutic process (coming on time, asking clarification questions and doing ‘homework’) is essential for achieving positive results. While there are potential risks involved, such as the possibility of encountering uncomfortable emotions like sadness, guilt, anger, and frustration when discussing personal challenges, psychotherapy/counseling also offers numerous benefits.

These may include improved interpersonal relationships, enhanced self-esteem, better problem-solving skills, finding solutions to specific issues, reduction in overall distress, as well as working through relational/intimacy-related issues. There are no instant solutions, and we cannot guarantee changes in your behavior or circumstances. However, we assure you of our support and commitment to understanding your concerns and recurring patterns, as well as assisting you in clarifying your personal goals. Participation in psychotherapeutic treatment is entirely voluntary, and you have the autonomy to discontinue treatment at any point.


Your sharing in this setting is confidential. All session content and relevant materials related to your treatment will be held in strict confidence unless you request in writing to disclose all or part of this information to specific individuals. In keeping with the ethical standards of the College of Psychologists of Ontario and provincial and federal privacy policies, we are committed to respecting and protecting your privacy. However, your confidentiality is limited by the legal requirements of our profession.

There are specific limitations to the confidentiality privilege, which include:

  • In situations where there is an immediate risk of harm to yourself or another person, your therapist is obligated by law to take steps to ensure safety by informing relevant individuals.
  • If you disclose information regarding child or elder abuse, your therapist is legally required to report it to the appropriate authorities.
  • If you disclose information about assault or abuse by a healthcare professional, your therapist is obligated by law to report this to the authorities.
  • If your therapist receives a court order for your clinical records or testimony, they will endeavor to discuss it thoroughly with you before taking any action, as such situations are rare.
  • Occasionally, we may need to consult with other professionals to ensure the most effective treatment for you, in such cases, information about you may be shared with a supervisor without disclosing your name.

If you happen to encounter your therapist accidentally outside the therapy setting, Evguenia will refrain from initiating acknowledgment out of respect for your privacy and confidentiality. However, if you initiate contact, she will be happy to briefly engage with you while maintaining discretion and avoiding extended discussions in public or outside the therapy environment.

Licensure and Extended Benefit Coverage

Evguenia Cheinis is currently pursuing her Master of Arts in Counselling Psychology at Yorkville University, which is an accredited psychotherapy training program recognized by the College of Registered Psychotherapists of Ontario (CRPO). Evguenia additionally holds membership as a Qualifying member of the CRPO and has 13 years of experience in facilitation energy therapy/sex education. She is also receiving professional supervision in couples and sex therapy, further enhancing her qualifications and ensuring the highest standard of care for her clients.

It’s important to note that while not all therapists are covered by insurance plans, some plans may offer a Health Care Spending Account that can be used to cover therapy costs. We will assist in processing your claim, but ultimately, it’s your responsibility to seek reimbursement. If therapy services are not covered by your benefits or you don’t have extended benefits, you may still be able to claim therapy costs on your income taxes. For more information, please consult with your therapist.

Session Payments

The fee for each 50-minute session is $175+HST for individual sessions or $200+HST for couple and relationship sessions. Evguenia additionally offers reduced rates, please reach out to Evguenia to discuss what will be feasible for your budget. She will be happy to explore available options as we prioritize your care.

Payment is due prior to the session start and can be made by email money transfer (preferred) or credit (VISA, Mastercard, or AMEX). To streamline payment processing, we are using Stripe and Acuity to process and store all credit cards. You may leave your credit card on file for automatic payment processing by providing your credit card number, expiration date, and CVC (3-digit code on the back of the card).

Account balances older than 30 days may be referred for reporting to the credit bureau. We will send friendly reminders before taking this step. Please contact us at your earliest convenience to avoid this process.

Cancellation Policy

If you need to reschedule the date or time of your appointment, please contact Evguenia by email at least 48 hours before the scheduled appointment. With sufficient notice, we can accommodate your request for a new appointment time. Additionally, this allows us to offer the previously reserved time slot to another client. We understand that unforeseen emergencies may arise, and we appreciate being notified as soon as possible if you’re unable to keep your appointment. We extend the same courtesy to you if your therapist ever needs to reschedule due to an emergency on their end.

In the event of a missed appointment without prior notice of at least 48 hours, or for non-emergency reasons, you will be invoiced for the session (equivalent to the full session fee). It’s important to note that insurance providers typically do not cover the costs associated with missed appointments.

Non-Disclosure of Materials

Material given to you in the course of our work together is proprietary, copyrighted, and developed specifically for us. You agree that such proprietary material is solely for your personal use. Any disclosure to a third party is strictly prohibited.

I am most happy to answer any questions regarding my studies/experience and I also encourage you to express any concerns you may have. In partnership for healing and with warm regards,


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