Counselling Intake Form

Counselling Intake Form
INTERESTED IN COUNSELLING?

Welcome! My name is Dar Debrecen. I'm a Counsellor, Social Worker, and Mental Health Educator at AVI Health Clinic. In my current role, I am able to offer free counselling to queer (and/or HIV+) 2SLGBTQI+ people in the Nanaimo Regional District.

Just fill in this intake form and I will get in touch with you by text or email to schedule a session. I can meet in person or online Mondays and Thursdays, and possibly online during other days of the week.

Feel free to email me at dar.debrecen@avi.org or text me at 1-250-818-5540 if you have any questions about me and my experience.

WILL MY SESSION BE RECORDED?

I only keep a record of who I saw and when. I do not keep notes on our sessions. You do not need to worry that any of your information other than your name will ever be passed on to other providers. If I leave the role, or if you're pursuing counselling else where and want me to discuss anything with them on your behalf, I am happy to do so.

OTHER MENTAL HEALTH RESOURCES:

I lead a free weekly yoga and meditation class, as well as free weekly and monthly educational programs on mental health and relationships. You can follow and join these programs through meetup: https://www.meetup.com/mindfulness-nanaimo/

The Mindful Health and Wellness program is for anyone wanting to learn more about mental, emotional, and spiritual health. The program is ideal for anyone wanting to understand and overcome anxiety and depression, but also for those wanting more powerful tools for self-development.

If you're interested in learning more about the biology of trauma, personal psychology and attachment theory, mindfulness and meditaton, then this program is for you. You can read more about it and apply to the program here: https://form.jotform.com/223428725539059

OTHER HEALTH AND WELLNESS RESOURCES:

I have a Major in Microbiology and a passion for science, anatomy and physiology, as well as all things natural that can improve our physical and mental health. I'm more than happy to discuss your physical health and to provide whatever direction that I can.
Your Name*

First NameLast Name
Your Pronouns*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Age*
Gender*
Where do you live? (for example: Nanaimo, Canada) *
Helping AVI Secure Funding

AVI is a non-profit health clinic. We operate on grants, some of which are issued specifically for serving certain populations. The information you provide will be kept confidential and the statistics we gather will be used to apply for grants that help fund the counselling program.
Do you self-identify as any of the following? Choose all that apply. Answering is voluntary and completely confidential.*

I prefer not to disclose.2SLGBTQI+Non-BinaryTrans ManTrans WomanGay MaleIndigenousNeurodivergentAs a person with a disability.Other
Who do you live with and what is the nature of your relationship, for example: parent, partner, friend, housemate etc. (optional)
Are you working or studying? Where do you work and what do you do? Do you work and or study part-time or full-time? (optional)
Are you coping with / managing or affected by any of the following? Check all that apply.

ADD / ADHDAutismDepressionCPTSDGeneralized AnxietySocial AnxietyPTSDSubstance UseNone of the AboveOther
Have you received a mental health diagnosis in the past? How do you feel about your diagnosis? How has this diagnosis helped or hindered you? (optional)
Are you coping with / managing or affected by any of the following? Check all that apply.

Breakup, Separation, DivorceDomestic ViolenceFinancial InstabilityGrieving a DeathLawsuits / Court ProceedingsPovertyProbation / IncarcerationStressful Work EnvironmentUnsafe Home EnvironmentUnstable HousingNone of the above.Other
Do you have any physical health conditions? Check all that apply.

Acid RefluxExcessive BloatingConstipationDiarrheaDiabetesAuto-Immune DiseaseNervous System DisorderCardiovascular DiseaseHormonal DisorderCancerNone of the above.Other
Are you taking any prescription medications or over the counter supplements for your mental or physical health? What are they, and have they been helpful? Have they had unwanted side-effects? (optional)
Do you have any other medical conditions that affect your mental, emotional or physical health that you might like to talk about? Answering is voluntary.
What are you currently doing to support your mental, emotional, physical and spiritual wellbeing? For example, are you being supported by other professionals, accessing other support services, meditating, exercising, dieting, etc.*
Would you like to receive an email with information on safe, affordable and effective interventions for health and wellbeing, for example, supplements and tools.

YesNo
Have you ever received counselling in the past? If so, what did or didn't you like about it? What would you like me to do differently than what you've experienced before? (optional)
If there's something specific you would like to talk about, feel free to share some details here. It's okay if you're not sure.
If there's something specific you would like to talk about, feel free to share some details here. It's okay if you're not sure.
RESPONSIBILITY AGREEMENT (LEGAL WAIVER)

HEALTH / MEDICAL ADVICE

During our therapy sessions, I may provide some information on medications, supplements, tools and practices intended to support your mental, emotional, physical and spiritual health. As I am not a doctor, naturopath or physiotherapist, I can't officially prescribe any of these medications, supplements, tools or practices to you as part of a treatment plan. It is your responsibility to do your own research and make an informed decision regarding all recommendations. All suggestions are completely optional.

CONFIDENTIALITY CONCERNS

In general, the privacy of all communications between a client (you) and the therapist (myself) is protected by law and I can only release information about our work to others with your written permission, but there are a few exceptions. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some of the information that we have discussed. For example, if I believe that a child, elderly person, or disabled person is being abused or has been abused, I may be required to make a report to the appropriate government agency. If I believe a client is threatening serious bodily harm to another, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If you (the client) threaten to harm yourself, I may be obligated to seek hospitalization for you or to contact family members who can help provide protection. If such a situation occurs in the course of our work together, I will attempt to fully discuss it with you before taking any action. Although this written summary of exceptions to confidentiality is intended to inform you about potential issues that could arise, it is important that we discuss any questions or concerns that you have. I will be happy to discuss these issues with you and provide clarification when possible. However, if you need specific clarification or advice I am unable to provide, formal legal advice may be needed, as the laws governing confidentiality are quite complex and I am not an attorney.

ACKNOWLEDING YOUR RESPONSIBILITY

By signing this document you acknowledge that I (Dareau Debrecen) do not regard myself as a medical professional, and that I (Dareau Debrecen) am not taking responsibility for your mental, emotional or physical wellbeing.

By signing this document you are acknowledging and claiming full responsibility for your own thoughts, feelings, and decisions. By signing this document you are
waiving any and all rights you have, or that anybody else has on your behalf to hold me, AVI Health Center, or its employees, responsible for any mental, emotional or physical harm that may come about in, or outside, of our work together.

Your signature below indicates that you have read the information in this document and agree to abide by its terms.
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Counselling Intake Form

Helping AVI Secure Funding