Burden Bearers Counselling Grande Prairie
Confidential Intake Interview Information Form
Personal Information
Today's Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Preferred Name(s) (if different)
Birthdate
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Month
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Day
Year
Date
Email
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example@example.com
Alternative Email
example@example.com
Address
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Street Address
Street Address Line 2
City
Province
Postal Code
Phone Number
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Area Code
Phone Number
The Phone Number is a
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Home Phone
Cell Phone
Work Phone
Other
Alternative Phone Number
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Area Code
Phone Number
The Alternative Phone Number is a
Home Phone
Cell Phone
Work Phone
Other
Occupation(s)
Relationship Status - Select all
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Single
Dating
Engaged
Married
Common-law
Separated
Divorced
Widowed
Dating- Whom
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Dating- How Long
Engaged- Whom
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Engaged- How Long
Married- Whom
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Married- How Long
Common-Law - Whom
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Common-Law - How Long
Separated - Whom
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Seperated- How Long
Divorced- Whom
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Divorced- How Long
Widowed- Whom
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Widowed- How Long
Current Partner's/Fiance's/ Spouse's Name
First Name
Last Name
His/Her Birthday
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Month
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Day
Year
Date
Do you have Children?
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Yes
No
What are your children's names and ages?
1 Child per line please
Have you had any previous counselling?
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Yes
No
Do you know of a relative/friend seeing a counsellor here?
YES
NO
If yes - are you seeking counselling related to issues with the above?
YES
NO
Referral Information
How did you hear about this office?
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Facebook
Webpage
Google
Doctor
Brochure
EAP
Church
Radio
Other
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Questionnaire of Concerns:
Medical Issues and Medications:
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Depression (If yes, when did it start):
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Anxiety (If yes, when did it start):
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Stresses:
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Sleep problems:
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Memory / Concentration concerns (Explain):
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Eating Concerns (If yes, what kind):
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Addictions (If yes, what kind ie. Substance, Gambling, etc):
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Thoughts or plans of self-harm:
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Abuse
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Past
Present
None
Unknown
Sexual
Emotional
Physical
Racism and/or Cultural Discrimination
Other
Sexual / Identity Concerns:
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Losses (If yes, What are they):
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Family Environment (Supportive or problematic?):
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Parental Issues:
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Work Situation (Supportive or problematic?):
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What resources or supports do you have in your life? (Community, faith, sports, friends, family, etc.):
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What do you hope to accomplish in counselling?
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Financial Commitment
I will pay the standard counselling fee of $140/hour either before or directly after my counselling session.
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Yes
No
I will pay with insurance
I wish to speak with office staff about eligibility for reduced fee sessions. I understand that eligibility is assessed based on acceptable proof of household gross annual income.
Yes
No, I will pay the standard rate of $140/hour.
I will pay for my sessions through direct billing by Burden Bearers to my insurance company.
Yes
No, I will pay the standard rate of $140/hour up front and submit my receipts to my insurance company.
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Counselling Contract
This contract is between BURDEN BEARERS COUNSELLING SOCIETY of Grande Prairie, Alberta (here and after known as “Burden Bearers”) and __________________________________, here and after known as the “Client”.
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First Name
Last Name
As a Christian-based organization, Burden Bearers respects the values and views of others. We provide services to those from all walks of life and belief systems.
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Understood
The Client promises to pay the fee for counselling as set out in their Financial Commitment on the Intake Interview Form, or as otherwise approved based on proof of income as stipulated in Burden Bearer's Reduced Fee Financial Policy. Burden Bearers is a non-profit, charitable counselling organization dependent on donations and client fees in return for professional counselling services. Our standard counselling rate based on current operating costs is $140.00 per hour. Third-party EAP billing rate is determined by the EFAP company and Burden Bearers.
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Understood
ATTENTION BEAVERLODGE CLIENTS: with regards to payment, please provide a credit card by phone to the Grande Prairie Burden Bearers office. You may choose to pay by e-transfer but we ask for a credit card to be on file.
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Understood
Counselling will seek to address issues of the whole person – emotions, thoughts, actions, and spiritual, as the Client directs.
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Understood
Typically, most people will come for hourly sessions on a weekly basis. This will be individualized to meet the Client’s specific needs.
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Understood
The Counsellor may take notes, during or after the sessions. These are the sole property of the counsellor. Unidentifiable statistical information may be used from the Client file for statistical reporting. We have a team approach here at Burden Bearers and it is a professional expectation that the Counsellor may, at his/her discretion, seek the aid of other Counsellors on staff for consultation and/or supervision in order to better serve the Client’s needs.
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Understood
The Counsellors and staff of Burden Bearers are bound by standards of professional, statutory, ethical conduct, and confidentiality at all times. There will be no confidential information divulged to any person or agency outside of the Client’s session without their written permission, except as provided for below.
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Understood
There are limitations to professional confidentiality where the Counsellor may be required to contact the appropriate authorities with the required information.
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Understood
These limits of confidentiality include:If a person is deemed by the Counsellor to be at a serious/severe risk of harming himself/herself or others
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Understood
These limits of confidentiality include: If there is reasonable suspicion of child abuse
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Understood
These limits of confidentiality include:Our records may be subpoenaed by a Court of Law and other legal limitations/requirements not set out herein.
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Understood
The Client is not bound to these counselling services. The Client is free to seek other counselling services or discontinue these counselling services at any time. Either the Client or the Counsellor may end the counselling process by giving reasonable notice (more than 24 hours prior to an arranged session.) If requested, the Counsellor will discuss other counselling options.
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Understood
The Counsellor will not accept any personal gifts for counselling services.
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Understood
If the Client is unable to attend his/her scheduled appointment and notifies the office staff more than 24 hours before the appointment time, there will be no charge. (Cancellations may be made 24 hrs. a day via the office voicemail.) You are free to refuse and/or withdraw from counselling at any time
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Understood
Because your appointment requires your therapist to reserve a significant amount of time exclusively for you, it is necessary to charge a half-fee for appointments that are not cancelled at least 24 hours in advance and the full client fee for no-show appointments. Exceptions such as bad roads, illnesses and family emergencies will be considered.
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Understood
A credit card number will be required upon booking your first appointment and will be charged for any no-show or last minute cancellations as per above.
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Understood, I will provide my credit card information by phone or in person before my first appointment.
Understood, you have my credit card on file already.
If the Client is behind on paying their fees and/or has missed several appointments without sufficient notice, Burden Bearers reserves the right to cancel all remaining appointments until the account is settled. If you are concerned about this, you may talk about it with office staff.
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Understood
Please inform your counsellor if you are going to be late for your appointment. Clients who are more than 15 minutes late, may forfeit their appointments. (With Pay)
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Understood
It is the client's responsibility to call our office for booked phone appointments and we will put you through to the counsellor
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Understood
If the Client requests a reference letter from his/her Counsellor to a third party, there will be a $50.00 fee for this letter, unless otherwise agreed upon with the Counsellor or the Office Manager.
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Understood
Today's Date
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Month
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Day
Year
Date
I, the Client, have read and understand this contract with Burden Bearers for counselling. I agree to fully participate in this counselling relationship.
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Signature
Submit
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