Qi Creative Psychotherapy Intake Form

You are completing the following intake forms: Child/Teen Intake and Consent form

Please complete this intake form prior to your in-person, telephone, or virtual therapy session. This form takes approximately 10 minutes to complete. Intake forms give your therapist important information about your life and situation, to better serve you. Questions followed by an asterisk or star * are required fields. All other fields are optional depending on your comfort level.

I authorize Qi Creative Inc. and its associated health professionals to collect my personal and medical information as documented above. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission except in situations where there is an immediate threat of danger to myself or others, or when required by law.

This notice describes how health information may be used and disclosed and how you can get access to this information. Please review it carefully.

I. OUR PLEDGE REGARDING HEALTH INFORMATION:

As clinicians, we understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from our clinicians. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of the child/teen's care generated by Qi Creative Inc. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information kept about you, and describe certain obligations we have regarding the use and disclosure of your health information. Qi Creative Inc. is required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of our legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• Qi Creative Inc. can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

Lawsuits and Disputes: If you are involved in a lawsuit, Qi Creative Inc. may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

Therapy/Chart Notes: Qi Creative Inc. clinicians keep session notes, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a) Required to help avert a serious threat to the health and safety of others.
b) Required to help avert a serious threat to the health and safety of yourself.

Marketing Purposes. As clinicians we do not share or disclose your PHI for marketing purposes.

Sale of PHI. As clinicians, we will not sell your PHI in the regular course of business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.

Subject to certain limitations in the law, Qi Creative Inc. can use and disclose your PHI without your Authorization for the following reasons:

• When disclosure is required by law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
• For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
• For health oversight activities, including audits and investigations
• For judicial and administrative proceedings, including responding to a court or administrative order, although our preference is to obtain an Authorization from you before doing so.
• For law enforcement purposes, including reporting crimes occurring on our premises.
• To coroners or medical examiners, when such individuals are performing duties authorized by law.
• For workers' compensation purposes. Although our preference is to obtain an Authorization from you, Qi Creative Inc. may provide your PHI in order to comply with workers' compensation laws.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

The Right to Choose How We Send PHI to You. You have the right to ask your clinician(s) to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and they will agree to all reasonable requests.

The Right to See and Get Copies of Your PHI. Other than “therapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that Qi Creative Inc. has about you. Qi Creative Inc. will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and may charge a reasonable, cost based fee for doing so.

The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE

This notice went into effect on September 1, 2025.

Acknowledgement of Receipt of Privacy Notice

Under the Health Information Act (HIA) in the province of Alberta, you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have read a copy of our Notice of Privacy Practices.

General Information: The therapeutic relationship is unique in that it is a highly personal and at the same time, contractual agreement. Given this, it is important for us to reach a clear understanding about how the therapeutic relationship will work and what each of us can expect. This consent will provide a clear framework for work together with your clinician. Feel free to discuss any of this with your clinical team members. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process: The outcome of the child/teen's treatment depends largely on theirs and their caregivers' willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. We cannot promise that your child/teen's behaviour or circumstance will change. We can promise to support everyone involved and do our very best to understand each person's challenges, capacities, and explore opportunities to move forward in a proactive and positive way.

Confidentiality: The session content and all relevant materials to the child/teen's treatment will be held confidential unless the caregiver requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such confidentiality exist and are itemized below:

• If the child/teen threatens or attempts to commit suicide, or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
• If the child/teen threatens grave bodily harm or death to another person.
• If the therapist has a reasonable suspicion that the child/teen or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
• Suspicions, as stated above, in the case of an elderly person who may be subjected to these abuses.
• Suspected neglect of the parties named in items #3 and #4.
• If a court of law issues a legitimate subpoena for information stated on the subpoena.
• If the client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
• Occasionally, your clinician may need to consult with other professionals in their areas of expertise in order to provide the best treatment for the child/teen. Information about the child/teen may be shared in this context without using their name.

If you happen to see a Qi Creative Inc. clinician outside of the therapy setting, they will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to us, and we do not wish to jeopardize your privacy. However, if you acknowledge them first, the clinician will be more than happy to speak briefly with you, but feel it is appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Appointments and Cancellations: Please remember to cancel or reschedule 24 hours in advance. You may be responsible for the entire fee if cancellation is made less than 24 hours before the scheduled time.

The standard meeting time for therapy is 50 minutes; however, Qi Creative also offers alternative session lengths to accommodate individual needs. You are billed for the time you meet with your therapist, plus an additional 10 minutes to allow for required chart notes afterwards (e.g., a 60-minute session is billed at a rate of $220/hr and includes 50 minutes with the client and 10 minutes for chart notes without the client).

Sessions that are extended beyond the time booked are subject to an additional cost, which will be billed at the $220/hr rate (e.g., if your session is extended from 50 minutes to 65 minutes, you will be billed $275). Please discuss this with your clinician if it concerns you or if you have any questions.

Cancellations and rescheduled sessions will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. The 24 hour notice is based on the start time of the visit. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

Telephone Accessibility: If you need to contact your clinician between sessions, please call the Qi Creative main phone line at (780) 670-8882 and add the clinician's specific extension when prompted. The clinician will attempt to return your message within 24 hours during the work week (Monday to Friday).

If a true emergency situation arises, please call 911, access your family physician, any local emergency room, or utilize any of the following support lines:

• CMHA Distress line available 24/7 at (780) 482-4357
• National Suicide Crisis Helpline at 988 (call or text)
• Alberta Health Services Mental Health Helpline at (877) 303-2642
• Children's Mental Health Crisis Line at (780) 427-4491
• Crisis and Stabilization Team at (780) 407-1000

Social Media and Telecommunication: Due to the importance of your confidentiality and the importance of minimizing dual relationships, Qi Creative clinicians do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of therapeutic relationships. If you have any questions about this, please bring them up when you next meet with your clinician.

Electronic Communication: Qi Creative cannot ensure the confidentiality of any form of communication through electronic media, including text messages. Let your clinician know your preference, if you prefer to communicate via email or text messaging for scheduling or cancellation issues.

While each clinician will strive to respond to messages in a timely manner, we cannot guarantee immediate communication through electronic media, including text messages. Qi Creative requests that you refrain from using these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

If you and your therapist choose to use information technology for some or all of your treatment (e.g. a telemedicine appointment rather than in-person), you need to understand that:

1. You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
2. All existing confidentiality protections are equally applicable.
3. Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
4. Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
5. There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs.

Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences.

When using information technology in therapy services, potential risks include, but are not limited to:

• The therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression.
• Potential consequences thus include the therapist not being aware of what they would consider important information, that you may not recognize as significant to present verbally the therapist.

Minors: Parents and caregivers may be legally entitled to some information about their child/teen's therapy. Your clinician will discuss with you and your child/teen what information is appropriate for them to receive, and which issues are more appropriately kept confidential.

Termination: Ending relationships can be difficult. Therefore, it is essential to have a termination process in place to achieve closure. The appropriate length of the termination depends on the length and intensity of the treatment. A clinician may terminate treatment after appropriate discussion with you and a termination process if the clinician determines that the therapy is not being effectively used, or if you are in default on payment. Qi Creative and their clinicians will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, Qi Creative's Clinical Director will assess which other qualified therapists may be able to treat you. You may also choose someone on your own or from another referral source.

Qi Creative Inc. stores client information electronically. Information is stored securely on an encrypted, Health Information Act (HIA) compliant server. All of your information is safely stored with bank-level data encryption technologies, compliant with current legal, ethical, privacy and security requirements. Where information can not be uploaded or stored on our electronic platform, paper records are kept secure on premises at the Qi Creative Inc. office. Our clinicians follow all guidelines laid out by their respective professional colleges for the secure storage of private health information and adhere to the standards of the Health Information Act (HIA).