APPLICATION FORM FOR FUNDING FOR THERAPY OR COUNSELLING (FOR THERAPIST/COUNSELLOR) – FORM B APPLICATION FORM FOR FUNDING FOR THERAPY OR COUNSELLING (FOR THERAPIST/COUNSELLOR) - FORM B All fields marked with * are mandatory. Therapist or Counsellor Information This form is to be completed by an applicant’s therapist or counsellor. A person who is eligible for funding may choose any therapist or counsellor subject to the following conditions: The therapist or counsellor must not be a person to whom the eligible person has any family relationship. The therapist or counsellor must not be a person who, to the College’s knowledge, has at any time or in any jurisdiction been found guilty of professional misconduct of a sexual nature or been found civilly or criminally liable for an act of a similar nature. If the therapist or counsellor is not a member of a regulated profession, the College may require the applicant to sign an acknowledgement indicating that they understand that the therapist or counsellor is not subject to professional discipline by a regulatory College. Therapist/Counsellor Name*: Address*: Telephone*: Email*: Payment Information Invoices for therapy and counselling can be submitted to: Mail: Ontario College of Social Workers and Social Service Workers(Attention: “Therapy Fund”) 250 Bloor Street East, Suite 1000 Toronto, Ontario M4W 1E6 Email: therapyfund@ocswssw.org Attestations I, (Therapist/Counsellor Name): of (Municipality): I certify that: I am a member in good standing with, name of regulated body: Registration Number: If registered in another jurisdiction, name of regulated body: I am not a member of any regulated professional body in Ontario or any other jurisdiction. If not regulated, please upload a copy of your curriculum vitae: Further Certification There has not been a finding of professional misconduct, incompetence, or incapacity in relation to my current profession. There has not been a finding of professional misconduct, incompetence, or incapacity in relation to another health profession in Ontario or any other jurisdiction. I am providing therapy/counselling to First Name: Last Name: Client Email Address: The therapy/counselling services are being provided in relation to practitioner sexual abuse. The funds being provided by the Ontario College of Social Workers and Social Service Workers are being used to cover the cost of this service. By clicking “Submit” I hereby confirm that I am the person identified on this form. Note: Please check your junk email folder if the confirmation email does not appear in your inbox.
