Year of Study. 1. Undergraduate Student 2. Graduate Student Professional Student Full-time Student Part-time Student Interest Student 3. Domestic Student International Student Exchange Student No Show Policy We ask for 24 hours notice when cancelling an appointment. If you miss your appointment without cancelling, fees will apply at the following rates SERVICE FEE QSAS session with an ASSESSIBILITY ADVISOR $30.00 Counselling session with a COUNSELLOR/MENTAL HEALTH NURSE $30.00 10 minute PHYSICIAN appointment $30.00 20 or 30minute PHYSICIAN appointment $60.00 60 minute PHYSICIAN/PSYCHOTHERAPY appointment $120.00 20-30 minute PSYCHIATRY appointment $60.00 31-60 minute PSYCHIATRY appointment $120.00 61-90 minute PSYCHIATRY appointment $180.00 10 minute NURSING appointment $10.00 Charges are to be paid at reception within 30 days. If payment is not received in 30 days the charges will be applied directly to your Queen’s SOLUS account. THIRD PARTY/UNINSURED SERVICES Not all medical services are covered by OHIP. These include insurance & other form completion, driver medicals, third party medicals, travel consultations/vaccinations, appeals, etc. Many are covered by your employer’s health insurance plan or other 3rd party insurance plans. Patients will be advised of such charges and payment methods. All charges for uninsured services must be settled at the point of services SIGNATURE: DATE: This information will be used to maintain client records. All privacy regulations as per PHIPA will be abided by. PLEASE NOTE: Student Wellness Services provides care to students currently enrolled at Queen’s University. In other situations, please discuss with the Clinic Manager. If you would be interested in participating in focus groups, interviews, or other similar activites to provide feedback / input on SWS programs and services, please check the box Yes, please contact me by email if there are opportunities to participate STUDENT WELLNESS SERVICES (SWS) STUDENT EMAIL CONSENT FORM * Student's Name: * Student's Date of Birth: * Student Number:
Year of Study. The NFSAS Funded student shall, in the first year of study and every year thereafter, comply with the following academic requirements:
