New Client Form

New Client Form
Client Information
NOTE: This form needs to be individually completed.

We want to make the most of each appointment you have with us. One way of doing this is for you to write down some basic information in advance of your first appointment. Please complete the following as completely as you can. This information is confidential. If you have concerns about the relevance of any information and wish to leave it out, please feel free to do so.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number*

Area CodePhone Number
Age*
Date of birth*

MonthDayYear
Date
Relationship Status*

SingleMarriedPartneredSeparated or SeparatingDivorcedWidow
Occupation*
Do you already have an appointment booked with us?*

Yes, an appointment is scheduledNot yetUnsure if an appointment is scheduled at this time
Spouse/Partner Name

First NameLast Name
Spouse/Partner's Phone Number

Area CodePhone Number
In your own words describe what motivates you to seek therapy*
How long have you noticed these concerns developing?*
In what ways have you attempted to resolve these concerns? What has been helpful and what has not worked?*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Confidentiality & Service Agreement
All records and communications about and the services provided are kept secure and confidential except within the situations listed:

• serious immediate threat to your life or welfare
• serious immediate threat to the life or welfare of another person
• actual or suspected child neglect (children under the age of 16)
• report of imminent danger to the community at large
• court subpoenas
• investigation by Child and Family Services Authority

If such a situation arises, your therapist will make every effort to fully discuss with you before taking any action and we will limit our disclosure to what is necessary. Your therapist may consult with other professional therapists, educators, and supervisors in order to provide you with the best treatment possible. I understand that information about treatment and care may be shared with other professionals for quality assurance, consultation and supervision purposes.
Professional Fees, Billing & Payment
I understand that my fee for counselling services is:*
Please select.
per 50 minute session or covered by Employee Assistance Plan. I understand that if the fees are not covered by Employee Assistance Plans, I am financially responsible for the fees owing. I understand that I will be charged the session fee if I do not cancel a scheduled appointment at least 24 hours prior to the appointment. I understand that acceptable forms of payment include cash, or credit card (3% processing fee) or EFT. I agree to keep a credit card on file and will be charged for the sessions if 24 hours notice is not provided.
I here-by consent to the provision of counselling services provided by:*
Please select.
Clients name:*

First NameLast Name
Clients signature:*

Clear
Date:*

MonthDayYear
Date
Client name (please type):*
gives permission for Luciak & Associates to process payment via the credit card account provided outlined for sessions cancelled with less than 24 hours notice.
Insurance and Direct Billing Plans
Direct Billing may be available for some insurance providers. Do you have an insurance plan?*

Yes (I am wanting direct billing and will provide the information below)Yes (but I will pay upfront and submit myself)No (I will pay debit/credit)
Health Insurance Provider:
Please select if you are wanting direct billing.
(Optional) If you are unsure of your policy numbers, you can upload a picture of your insurance card here:

Browse Files

Cancelof
Group Number
Plan or Member I.D. #
Birthdate:
Consent for Teletherapy
I understand that I have the following rights with respect to teletherapy:

1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

2. The laws that protect the confidentiality of my counselling information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
Consent*

YesNo
Clients Signature*

Clear
Credit Card Information
Upon completion of this intake form you will be redirected to a form to provide credit card information.

This is necessary in the event of appointments cancelled with less than 24 hours notice.
Should be Empty:

New Client Form

Client Information

Confidentiality & Service Agreement

Professional Fees, Billing & Payment

Insurance and Direct Billing Plans

Consent for Teletherapy

Credit Card Information