One to One Online Art Therapy Sessions – Adult Consent & Intake Form

One to One Online Art Therapy Sessions – Adult Consent & Intake Form

Thank you so much for your interest in working with me one to one in online art therapy sessions. I look forward to journeying with you. This form gives me information about who you are, what you would like to work on in our sessions and gives you your rights as a client. Please carefully complete this form before our first session together. I will go over some parts of this form with you during our first session. If you have any questions about the form please reach out to Katlyn (blueflamearttherapy@gmail.com).
Personal Information
Full Name*

First NameLast Name
Preferred Name (if different)
Sex & Gender*

Sex (as assigned at birth)Gender (current gender, which may be different than what is indicated on your insurance policies or medical record)
Pronouns
Contact Information*

Phone NumberEmail
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Occupation
Emergency Contact Name*
First and Last Name
Emergency Contact Phone*
Please enter a valid phone number.
Emergency Contact Relationship*
Family Doctor Name
Family Doctor Phone (if known)
Please enter a valid phone number.
Family Doctor Email (if known)
example@example.com
Referring Professional Name
Referring Professional Phone (if known)
Please enter a valid phone number.
Referring Professional Email (if known)
example@example.com

Intake Questionnaire

Please review the questions below, and answer them to the best of your ability at this time. This helps me understand how I can best support you.
What has led you to seek art therapy at this time?*
How long have you been having these difficulties?*
How do these difficulties affect your life? (Please answer for each area that applies and write N/A for any that don't apply)
Work*
School*
Finances*
Health/Wellbeing*
Relationships*
Other (not listed above)
How have you been coping with these difficulties until now?*
Have you received art therapy or therapy in the past? If yes, what did you find helpful?*
What would you like to gain from art therapy at this time?*
Alcohol/substance useSignificant life changes or stressful eventsSignificant losses or traumasAny personal or family history of suicidal ideation, risk, or attempt (please specify when below)I have experienced none of these above
For the areas you have checked above please share more about when these experiences happened, how long it lasted, and other details you would be willing to share or write N/A if it doesn't apply.*
Do you have any spiritual beliefs/practices that are important to you?
What are your strengths? Who or what resources you? (people/animals/activities)*
Please add anything else that you would like me to be aware of to support your art therapy experience

Virtual Art Therapy Informed Consent – Adult

This form lays out your rights as a client and helps us both create a safe space with each other.
Participation Consent
I agree to participate in virtual art therapy sessions facilitated by the art therapist Katlyn Lim. Katlyn is supervised by an art therapist registered with the Canadian Art Therapy Association (CATA) and adheres to the CATA Standards of Practice. I understand that records of therapy sessions will be maintained and that these records are confidential and stored securely according to the provincial privacy standards.
I understand and consent to the above statement about my participation in virtual art therapy (please initial)*
Please initial
Safe Online Therapeutic Space
- My art and aspects of my art therapy sessions may be shown and discussed with the art therapist’s supervisor in individual supervision. I understand that the art therapist and supervisor are held accountable to the ethics of the profession with regard to client confidentiality.
- The use of the Google Meet video platform. The security of this platform cannot be guaranteed by Blue Flame Art Therapy. However, Google Meet does protect privacy by using anti-hijacking controls for video meetings and is encrypted thus securing data in transit. The only personal health information that Google Meet will have access to is my name and email address, and only for the purposes of setting up session times.
- I will create a safe and uninterrupted space to ensure confidentiality during the video session. I understand that my space at home becomes part of the virtual art therapy studio. This means that I will ensure that others will not enter my space, and I will minimize background noise and distractions (such as notifications on devices).
- I will prepare for the video session by coming dressed in appropriate attire for an appointment with a professional, setting up my device five minutes in advance of the start time, and having my artwork/writing/questions/reflections ready to share, if needed.
- If I am interested in making art prior to/during the video session, I will take responsibility to have a variety of art materials of my choice. The therapist will provide support in planning for useful art materials and art directives.
- I understand that neither myself nor the art therapist are permitted to record the video sessions, unless written consent is provided by both parties.
- If there is an internet connection issue during the session, I will close the application and try again. If unable to connect, I will wait for the art therapist to connect with me via telephone.
I understand and consent to the use of secure video conferencing (Google Meet), supervision, and session preparation requirements (please initial)*
Please initial
Client Rights
- I have the right to end therapy at any time, for any reason, or for no reason. You always have the right to seek alternative treatment, including a different therapist.
- It is encouraged to discuss termination with the art therapist when possible so that closure can be processed together, and other suitable community or professional resources may be discussed that you may be interested in accessing.
I understand and consent to the client rights described (please initial)*
Please Initial
Risks and Benefits
- Participating in any psychotherapy sessions has its risks and benefits, and it’s important that you are aware of the most likely cases.
- Risks may include, but are not limited to, having uncomfortable feelings/thoughts, difficult memories are brought up, gaining new skills/confidence that impact areas of your life, or shifts in relationships with others. It is not unusual for you to feel worse after you start counselling or after a session, but these feelings should decrease as time goes on.
- Benefits may include, but are not limited to, improved connections with yourself and/or others, elevated mood, more effective communication, a boost in psychological well-being, decreased effects of personal problems and better regulation and coping skills.
I understand and consent to the risks and benefits described (please initial)*
Please initial
Payment and Cancelation
- Payments may be e-transferred to Katlyn through the email blueflamearttherapy@gmail.com or paid through Stripe through Google calendar. If payment can’t be made through email, or Stripe, other options will be discussed and agreed upon with the art therapist.
- If using a sliding scale, the art therapist and I will determine the costs of the sessions together. The cost of sessions will be put into the client files and changed as needed.
- I will try to cancel an appointment 12 hours before it starts. If a session was paid for but the art therapist needs to cancel due to health or emergency reasons they will refund the client fully for this session or use the money for the next scheduled session.
- If I have attended one session but have not paid for it the art therapist will suspend their services until payment is made for this session.
I understand and consent to the payment and cancellation policy (please initial)*
Please initial
Limits of Confidentiality
I understand that all my personal information will be kept confidential unless:
- there is a threat of bodily harm to self or others
- there is indication of child and/or elder abuse
- the information is requested by subpoena for court purposes
- permission is given to consult with other individuals/professionals as required
I understand and consent to the limits of confidentiality described (please initial)*
Please initial
Signatures
Client Name*
Client Signature*

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One to One Online Art Therapy Sessions – Adult Consent & Intake Form

Personal Information

Intake Questionnaire

How do these difficulties affect your life? (Please answer for each area that applies and write N/A for any that don't apply)

Online Format

Payments

Standard Rate

Sliding Scale

Starter Packages

Virtual Art Therapy Informed Consent – Adult

Participation Consent

Safe Online Therapeutic Space

Client Rights

Risks and Benefits

Payment and Cancelation

Limits of Confidentiality

Signatures