Quotation Estimate Psychiatrist in Canada Montreal –Free Word Template Download with AI

Quotation Estimate

Quotation Details

Quotation No.: QTE-2025-MTL-0347

Date Issued: June 12, 2025

Valid Until: July 12, 2025

Prepared By: Dr. Émilie Tremblay, MD, FRCPC

Specialty: Psychiatrist – Adult & Adolescent Mental Health

Client Information

Client Name: [Client Full Name]

Address: [Street Address], Montréal, Québec, Canada

Telephone: (514) ___-____

Email: [[email protected]]

Insurance Provider: [Provider Name / Plan No.]

Dear Valued Client,

Thank you for considering the psychiatric services offered by the Centre de Santé Mentale de Montréal. This Quotation Estimate has been prepared specifically for your consultation and ongoing treatment plan with our licensed Psychiatrist in the greater Montreal, Canada metropolitan area. The following document outlines the scope of services, associated fees, and terms applicable to your care. All pricing is presented in Canadian Dollars (CAD) and reflects current rates as of June 2025 in the Province of Québec.

Itemized Services and Fees

#	Description of Service	Duration	Frequency	Unit Price (CAD)	Estimated Total (CAD)
1	Initial Comprehensive Psychiatric Evaluation – Full clinical assessment including medical history review, mental status examination, diagnostic formulation, and treatment planning conducted by a board-certified Psychiatrist in Montreal, Canada.	90 minutes	One-time	$350.00	$350.00
2	Follow-up Psychiatric Consultation – Ongoing monitoring of treatment progress, medication management, and therapeutic adjustments. Includes review of any laboratory results or collateral reports.	45 minutes	Monthly (x6)	$225.00	$1,350.00
3	Psychiatric Medication Management & Prescription Renewal – Detailed review of current psychotropic medications, dosage adjustments, side-effect monitoring, and issuance of prescriptions compliant with Québec College of Physicians and Surgeons regulations.	30 minutes	Monthly (x6)	$150.00	$900.00
4	Psychological Testing & Neuropsychological Assessment – Administration and interpretation of standardized diagnostic instruments (e.g., PHQ-9, GAD-7, MMSE, BDI-II) to support the Psychiatrist's clinical decision-making in Montreal, Canada.	60 minutes	One-time	$275.00	$275.00
5	Crisis Intervention & Urgent Psychiatric Consultation – Available on a 48-hour notice basis for acute episodes. Includes telephone triage, in-person or telehealth assessment, and emergency treatment plan. Subject to availability of the Psychiatrist.	45 minutes	As needed (est. x2)	$280.00	$560.00
6	Psychiatric Report & Documentation – Written clinical report for insurance purposes, disability claims, legal proceedings, or employer accommodation requests. Prepared in accordance with Canadian privacy legislation (PIPEDA and Québec Law 25).	—	One-time	$185.00	$185.00
7	Telehealth / Virtual Psychiatric Consultation – Secure video consultation with the Psychiatrist for clients residing in the Montreal, Canada region or surrounding areas (Laval, Longueuil, South Shore). Compliant with Québec telehealth regulations.	45 minutes	Monthly (x3)	$195.00	$585.00
Subtotal (CAD)					$4,205.00
Estimated Québec Sales Tax (QST) 5%					$210.25
Grand Total (CAD)					$4,415.25

Notes and Assumptions

This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issuance. Fees are subject to revision in accordance with the fee schedule published by the Collège des médecins du Québec.
All services are to be delivered by Dr. Émilie Tremblay, a licensed Psychiatrist registered with the Collège des médecins du Québec, or by a designated associate Psychiatrist of equivalent standing at the Centre de Santé Mentale de Montréal.
Medication costs, laboratory tests ordered by the Psychiatrist, and hospitalization fees are not included in this Quotation Estimate and will be billed separately at cost.
Where applicable, a portion of the fees may be reimbursed through your extended health insurance plan or through the Régie de l'assurance maladie du Québec (RAMQ) for eligible services. The client is responsible for any non-covered amounts.
Telehealth consultations are conducted via a HIPAA/PIPEDA-compliant platform. The client must reside within the Province of Québec, Canada, to receive virtual psychiatric services.
Cancellation or rescheduling of appointments must be made at least 24 hours in advance. Late cancellations or no-shows will be charged at 50% of the applicable session fee.

Payment Terms

Payment is due within fifteen (15) calendar days of the date of each invoice. A 2% late-payment surcharge will apply to balances outstanding beyond the due date.
Accepted payment methods include: Interac e-Transfer, debit/credit card (Visa, Mastercard, Amex), cheque payable to Centre de Santé Mentale de Montréal, and direct bank transfer.
For clients with extended health insurance, the office will submit claims on the client's behalf. The client is responsible for any co-payment or deductible amounts not covered by the insurer.
A deposit of 20% of the total estimated amount is required to secure the initial evaluation appointment. The remaining balance will be invoiced monthly as services are rendered.

Confidentiality and Privacy

All clinical information, diagnostic records, and treatment details are protected under the Personal Information Protection and Electronic Documents Act (PIPEDA) and Québec's Act respecting the protection of personal information in the private sector (Law 25). The Psychiatrist and all staff members are bound by strict confidentiality obligations. Information will not be disclosed to third parties without the client's written consent, except where required by Canadian law (e.g., court order, mandatory reporting of imminent risk of harm).

Client Acknowledgement and Acceptance

By signing below, the client acknowledges receipt of this Quotation Estimate, confirms understanding of the services, fees, and terms outlined herein, and authorizes the Centre de Santé Mentale de Montréal to proceed with the psychiatric services described. The client further consents to the collection, use, and disclosure of personal health information solely for the purpose of delivering psychiatric care in Montreal, Canada.

Client Signature & Date Dr. Émilie Tremblay, MD, FRCPC – Psychiatrist ⬇️ Download as DOCX Edit online as DOCX

Create your own Word template with our GoGPT AI prompt:

GoGPT