This form contains important information about directions, parking, reception, COVID-19 safety protocols, and cancellation policies. Please read the document carefully before booking your consultation.
Welcome to Sharon Blott Psychological Services. Please review the following information before your appointment.
DIRECTIONS:
Sharon Blott Psychological Services is located within the Smart Executive Centre which is located at 1925 – 18th Avenue NE. Please note that if you are using GPS, it will take you to the back of the building and there is no entrance there. The main entrance is on the South side. There is plenty of free parking marked Visitor/Smart Executive Guest. The Business Centre is located at Suite 115, on the 1st floor, to the right of the atrium. Please check in with the receptionist and she will let me know of your arrival. If the receptionist is not at the desk, you may text me at 403-612- 3396. For weekend appointments, please note that the outside doors are locked. Your psychologist will meet you at the front doors approximately five minutes before your scheduled appointment and bring you to the office.
COVID PROTOCOL: Masks are mandatory in the office. All COVID-19 safety protocols are in place in the office for your appointment including hand sanitizer and a plex-glass screen at the table where testing is administered.
FEES:
A flat rate is charged for all services. Payment is discussed during the intake meeting, and can be made by cash, email interac transfer, Visa, MasterCard, or AMEX. An invoice will be provided that you can submit to your insurance company for reimbursement. We also offer direct billing for several insurance providers excluding Sunlife and Manulife.
OFFICE POLICIES: Please only send peanut/tree-nut free snacks with your child. We respectfully request that if you or your child is ill for any reason, you reschedule your appointment (without additional charges) to ensure an optimal assessment environment and accurate results. We would appreciate 24 hours’ notice if need to change your scheduled appointment time. A 30-minute fee ($100) is charged for no-show appointments or last minute cancellations. Thank you again for contacting Sharon Blott Psychological Services. We look forward to meeting you. I have read and agree to the above.
Benefit Assignment Form
The benefit assignment form will help us to direct bill your insurance company. We also require your credit card details for billing in case your insurance does not cover the benefits. Please read the form to understand the requirements. No billing will be done to your freit card without prior notice.
Instructions: This form must be filled out when claim payment is assigned to the Provider. Please retain this form in the patient’s file for verification purposes for two years following closure of the patient file.
Electronic Transmission Authorization and Consent Form
This authorization form is required for us to claim your benefits from your insurance provider on your behalf. The form also helps us get consent to use patient information for the transaction with the authorized insurance provider.
Instructions: This form must be filled out when claims are submitted electronically by the provider on the patient’s behalf. Please retain this form in the patient’s file for verification purposes for two years following closure of the patient file.
Informed Consent Forms
These forms contain details about your psychologists, assessments, and fees. We require your consent to all information given in these forms before beginning with your assessment. Your consent will help foster a good client-therapist relationship. The consent forms also protect your rights and safeguard you from any harm.
Sarra Ng
Informed Consent Forms
These forms contain details about your psychologists, assessments, and fees. We require your consent to all information given in these forms before beginning with your assessment. Your consent will help foster a good client-therapist relationship. The consent forms also protect your rights and safeguard you from any harm.
Sharron Blott
Release of Information Form
Any information about your diagnosis will only be shared with your physicians, teachers or pediatrician after your consent. This form is typically signed at the completion of services and only after the discussion is held about doing so. The consent to release/obtain information is valid for one year.