Forms


Consent Form

Here are some forms to review before your first session. They can be completed on your computer and emailed to your clinician, or you can simply complete and print them and bring them into your first session. Please make sure to print off both your clinician’s consent form and the basic information form.

Dr. Sarah Bellefontaine Consent Form

Kellye Woods Consent Form

Dr. Andrea Azurdia Consent Form

As a current employee of the Ottawa-Carleton District School Board (OCDSB), Dr. Azurdia must follow the school board’s conflict of interest and confidentiality guidelines. This means that she is unable to see any child in her private practice who attends one of her assigned schools. This does not apply if your child attends an OCDSB school that Dr. Azurdia is not currently assigned to. Should you decide to enlist Dr. Azurdia’s services, you will be asked to sign a waiver form (below) acknowledging that you understand free services are available to your child, if eligible, through his or her school, and that you have elected to retain services privately.

Dr. Andrea Azurdia Conflict of Interest Waiver OCDSB

 

Basic Information Form

Please choose one of the following versions for our basic information form. The first lets you print and then fill it out by hand, the second allows you to fill it out using Microsoft Word, and then print it.

Printable PPCS basic information form

Form-Fillable PPCS basic information form