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 Thrive Business Centre which is
located at Suite 105,11500-29th Street SE. The building can easily be accessed off of
Deerfoot Trail and the Douglasdale/24th Street exit, or off of Barlow Trail/Stoney Trail
and 114th Avenue. The main entrance for Unit 105 is on the northeast side of the building.
You will see Anytime Fitness in the same building. There is plenty of free parking.
Upon your arrival, please check in electronically at the computer next to the reception desk
by entering your psychologist’s name, and we will be sent a message that you have arrived.
Please ensure to enter the correct name (i.e., if you are seeing Sharon Blott, click on that link,
if you are seeing Sarra Wong, click on her link). Please have a seat in the waiting area.
COVID PROTOCOL: Masks continue to be worn 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: We respectfully request that if you are 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 for any
other reason. 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.
appointment
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.
benefit
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.
electronic
INFORMED CONSENT FOR PSYCHOLOGICAL SERVICES
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 Wong
sarra
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.
Sharon Blott
sharon
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.